Provider Demographics
NPI:1922391739
Name:BLUEGRASS DRUG CENTER, INC.
Entity type:Organization
Organization Name:BLUEGRASS DRUG CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-255-3540
Mailing Address - Street 1:835 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-3131
Mailing Address - Country:US
Mailing Address - Phone:812-265-4621
Mailing Address - Fax:812-273-6666
Practice Address - Street 1:325 HIGHWAY 42 E
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:KY
Practice Address - Zip Code:40006-7624
Practice Address - Country:US
Practice Address - Phone:502-255-3540
Practice Address - Fax:502-255-3615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP074523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130610OtherPK
KY7100162110Medicaid