Healthcare Provider Details

I. General information

NPI: 1417067729
Provider Name (Legal Business Name): J W PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 MAIN ST
BENTON KY
42025-1240
US

IV. Provider business mailing address

817 MAIN ST
BENTON KY
42025-1240
US

V. Phone/Fax

Practice location:
  • Phone: 270-527-9374
  • Fax: 270-527-3152
Mailing address:
  • Phone: 270-527-9374
  • Fax: 270-527-3152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number00663
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number00663
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number00663
License Number StateKY

VIII. Authorized Official

Name: JAMES H WISEMAN
Title or Position: OWNER PRES
Credential:
Phone: 270-527-9374