Provider Demographics
NPI:1174615124
Name:CLARKSON DRUG STORE, INC.
Entity type:Organization
Organization Name:CLARKSON DRUG STORE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-242-3811
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:CLARKSON
Mailing Address - State:KY
Mailing Address - Zip Code:42726-0146
Mailing Address - Country:US
Mailing Address - Phone:270-242-3811
Mailing Address - Fax:270-242-4171
Practice Address - Street 1:201 MILLERSTOWN ST.
Practice Address - Street 2:
Practice Address - City:CLARKSON
Practice Address - State:KY
Practice Address - Zip Code:42726-0146
Practice Address - Country:US
Practice Address - Phone:270-242-3811
Practice Address - Fax:270-242-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP00450332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000070017OtherANTHEM BC & BS
1802811OtherNABP
KY54002209Medicaid
KY90020439Medicaid
KY0156750001Medicare NSC