Provider Demographics
NPI:1679571830
Name:COMMONWEALTH OF KENTUCKY
Entity type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAYCRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-782-6243
Mailing Address - Street 1:2441 SOUTH HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501
Mailing Address - Country:US
Mailing Address - Phone:606-677-4068
Mailing Address - Fax:606-677-4079
Practice Address - Street 1:2441 SOUTH HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501
Practice Address - Country:US
Practice Address - Phone:606-677-4068
Practice Address - Fax:606-677-4079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-12
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100426320600000X
KYPO5076333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54025580Medicaid
KY11914025Medicaid