Organization
LAKE CUMBERLAND PHARMACY LLC
Active
Other names
Lake Cumberland Pharmacy #2
Organization subpart
No
Provider details
NPI number
Authorized official
JONATHAN GRIDER PHARMD (MANAGING MEMBER)
(270) 858-6400
Entity
Organization
Contact information
Practice address
124 DOWELL RD, RUSSELL SPRINGS, KY 42642-4278
(270) 866-2686
(270) 866-6566
Mailing address
PO BOX 72, RUSSELL SPRINGS, KY 42642-0072
(270) 866-2686
Taxonomy
Speciality
Code
Description
License number
State
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
P07440
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2128898
PK
—
05
—
7100171840
—
KY
Enumeration date
01/05/2011
Last updated
10/07/2022
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