Organization
LAKE CUMBERLAND PHARMACY LLC
Active
Other names
Lake Cumberland Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
JONATHAN GIDER PHARMD (PHARMACIST-IN-CHARGE)
(270) 585-2221
Entity
Organization
Contact information
Practice address
2431C LAKEWAY DR, RUSSELL SPRINGS, KY 42642-4510
(270) 858-6400
(270) 866-7542
Mailing address
PO BOX 72, RUSSELL SPRINGS, KY 42642-0072
(270) 585-2221
Taxonomy
Speciality
Code
Description
License number
State
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
P07417
KY
3336H0001X
Home Infusion Therapy Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2127210
PK
—
05
—
7100146780
—
KY
Enumeration date
10/18/2010
Last updated
11/14/2024
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