NPIMap

Organization Active NPI

Eastridge-Phelps Pharmacy LLC

  • Community/Retail Pharmacy
  • Campbellsville, KY
National Provider Identifier
1245478007
Registry record updated Mar 5, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
P07325 Issued in KY
Legal business name
EASTRIDGE-PHELPS PHARMACY LLC
Practice address
101 Winston Way
Suite a
Campbellsville, KY 42718-4953
Phone
(270) 789-0577
Fax
(270) 789-0578
NPI assigned
Jan 31, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 5, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Chad Phelps
Title
Pharmacist/Pic/Member
Phone
(270) 789-0577

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X P07325 KY Primary

Addresses

Primary practice location

101 Winston Way
Suite a
Campbellsville, KY 42718-4953

Mailing address

101 Winston Way
Suite a
Campbellsville, KY 42718-4953
Phone (270) 789-0577

Other identifiers 2

IdentifierTypeStateIssuer
1831038OtherNCPDP PROVIDER IDENTIFICATION NUMBER
7100060880MedicaidKY

Other names 1

  • Eastridge-Phelps Pharmacy Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100723000530 KY Part B Supplier - Mass Immunization (Roster Biller Only) 5698807881 Practice locations: Campbellsville, KY
O20100930031997 KY DME Supplier - Pharmacy 5698807881 Practice locations: Campbellsville, KY

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Eastridge-Phelps Pharmacy LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

101 Winston Way
Lot A
Campbellsville, KY 42718
Phone (270) 789-0577

500 N Bypass Rd
Ste A
Campbellsville, KY 42718

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1233360000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1614902400000",
    "number": "1245478007",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "101 WINSTON WAY",
            "address_2": "SUITE A",
            "city": "CAMPBELLSVILLE",
            "state": "KY",
            "postal_code": "427184953",
            "telephone_number": "270-789-0577",
            "fax_number": "270-789-0578"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 WINSTON WAY",
            "address_2": "SUITE A",
            "city": "CAMPBELLSVILLE",
            "state": "KY",
            "postal_code": "427184953",
            "telephone_number": "270-789-0577",
            "fax_number": "270-789-0578"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTRIDGE-PHELPS PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-01-31",
        "last_updated": "2021-03-05",
        "certification_date": "2021-03-05",
        "status": "A",
        "authorized_official_last_name": "PHELPS",
        "authorized_official_first_name": "CHAD",
        "authorized_official_title_or_position": "PHARMACIST/PIC/MEMBER",
        "authorized_official_telephone_number": "270-789-0577"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "KY",
            "license": "P07325",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "1831038",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100060880",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Eastridge-Phelps Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Campbellsville, KY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 5, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.