Provider Demographics
NPI:1043497480
Name:WESTERN STATE HOSPITAL PHARMACY
Entity type:Organization
Organization Name:WESTERN STATE HOSPITAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTFALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-889-6025
Mailing Address - Street 1:2400 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-8095
Mailing Address - Country:US
Mailing Address - Phone:270-889-6025
Mailing Address - Fax:270-889-5062
Practice Address - Street 1:2400 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-8095
Practice Address - Country:US
Practice Address - Phone:270-889-6025
Practice Address - Fax:270-889-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP050103336I0012X
KYP065613336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5402559800Medicaid