Healthcare Provider Details

I. General information

NPI: 1932442266
Provider Name (Legal Business Name): MIDTOWN PHARMACY EXPRESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N MAIN ST
BEAVER DAM KY
42320-1949
US

IV. Provider business mailing address

500 N MAIN ST P.O. BOX 125
BEAVER DAM KY
42320-1949
US

V. Phone/Fax

Practice location:
  • Phone: 270-274-9224
  • Fax: 270-274-9226
Mailing address:
  • Phone: 270-274-9224
  • Fax: 270-274-9226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP07565
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHNATHAN FULLER
Title or Position: OWNER
Credential: PHARM.D.
Phone: 270-274-9224