Healthcare Provider Details

I. General information

NPI: 1174898746
Provider Name (Legal Business Name): EAST MAIN STREET PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 E MAIN ST
HAZARD KY
41701-1920
US

IV. Provider business mailing address

PO BOX 2069
HAZARD KY
41702-2069
US

V. Phone/Fax

Practice location:
  • Phone: 606-487-0107
  • Fax: 606-487-0104
Mailing address:
  • Phone: 606-487-0107
  • Fax: 606-487-0104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP07502
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DACHEA WOOTON
Title or Position: OWNER,PIC,AO
Credential: RPH
Phone: 606-487-0107