Basic Information
| Provider Information | |||||||||
| NPI: | 1902970304 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DANVILLE VALUE PHARMACY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GOOD NEIGHBOR PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 60 CASSIDY WAY # 3 | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404228457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599361222 | ||||||||
| FaxNumber: | 8599362003 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 CASSIDY WAY # 3 | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404228457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599361222 | ||||||||
| FaxNumber: | 8599362003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 08/29/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLOAT | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | KENNETH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8599361222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | P06861 | KY | N | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | 332B00000X | P06861 | KY | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | P06861 | KY | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1827938 | 01 | KY | NABP | OTHER | 54005095 | 05 | KY | MEDICAID | 90007733 | 05 | KY | MEDICAID |