Lake Cumberland Pharmacy LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

P07440 Issued in KY

Legal business name

LAKE CUMBERLAND PHARMACY LLC

Doing business as

Lake Cumberland Pharmacy #2

Practice address

124 Dowell Rd
Russell Springs, KY 42642-4278

Phone

(270) 866-2686

Fax

(270) 866-6566

NPI assigned

Jan 5, 2011

Last updated

Oct 7, 2022By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Jonathan Grider, PHARMDNPI 1518675628

Title

Managing Member

Phone

(270) 858-6400

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• Lake Cumberland Pharmacy #2 Doing business as

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jonathan Grider, PHARMD

  • Pharmacist
  • Russell Springs, KY
  • NPI 1518675628
  NPD Authorized official
• Brittany Antle, PHARMD

  • Pharmacist
  • Russell Springs, KY
  • NPI 1508574617
  NPD (past)

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

{
    "created_epoch": "1294185600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1665100800000",
    "number": "1912201906",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 72",
            "city": "RUSSELL SPRINGS",
            "state": "KY",
            "postal_code": "426420072",
            "telephone_number": "270-866-2686"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "124 DOWELL RD",
            "city": "RUSSELL SPRINGS",
            "state": "KY",
            "postal_code": "426424278",
            "telephone_number": "270-866-2686",
            "fax_number": "270-866-6566"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE CUMBERLAND PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-01-05",
        "last_updated": "2022-10-07",
        "certification_date": "2022-10-07",
        "status": "A",
        "authorized_official_last_name": "GRIDER",
        "authorized_official_first_name": "JONATHAN",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "270-858-6400",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "332BP3500X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Parenteral & Enteral Nutrition",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "KY",
            "license": "P07440",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100171840",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2128898",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Cumberland Pharmacy #2",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Lake Cumberland Pharmacy #2",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Lake Cumberland Community Action Agency, Inc.
• Lake Cumberland District Health Dept (Russell County High School)
• Lake Cumberland District Health Dept (Russell County Middle School)
• Lake Cumberland District Health Dept (Salem Elementary School)
• Lake Cumberland District Heatlh Dept (Russell Springs Elementary School)
• Lake Cumberland Pharmacy LLC (Lake Cumberland Pharmacy)
• Lake Cumberland Physician Practices, LLC (Russell County Medical Associates)
• Lake Cumberland Veterans Directed Services
• Laker Drug Inc. (laker drug)
• Lakeside Home Medical Equipment Inc

• Community/Retail Pharmacy in Russell Springs, KY
• Providers in Russell Springs, KY by specialty
• Community/Retail Pharmacy in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 7, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.