Basic Information
| Provider Information | |||||||||
| NPI: | 1255312062 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DANVILLE VALUE PHARMACY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 60 CASSADY AVE #3 | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599361222 | ||||||||
| FaxNumber: | 8599362003 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 CASSADY AVE #3 | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599361222 | ||||||||
| FaxNumber: | 8599362003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLOAT | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8599361222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | KY | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
| ID | Type | State | Issuer | Description | 90007733 | 05 | KY | MEDICAID |