Organization
BLACKLOG APOTHECARY INC
Active
Organization
BLACKLOG APOTHECARY INC
Active
Other names
MEDICINE SHOPPE
Organization subpart
No
Provider details
NPI number
Authorized official
RANDALL BERRY CHAFFIN RPH (OWNER PHARMACIST)
(606) 298-7774
Entity
Organization
Contact information
Practice address
62 KIRK PLZ, INEZ, KY 41224-6501
(606) 298-7774
(606) 298-4975
Mailing address
62 KIRK PLZ, INEZ, KY 41224-6501
(606) 298-7774
(606) 298-4975
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
P01894
KY
333600000X
Pharmacy
P01894
KY
3336C0003X
Community/Retail Pharmacy
Primary
—
—
3336C0004X
Compounding Pharmacy
P01894
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1817230
OTHER ID NUMBER-COMMERCIAL NUMBER
—
05
—
54020623
—
KY
05
—
9008080500
—
KY
Enumeration date
01/30/2007
Last updated
03/07/2023
Update your record
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