Healthcare Provider Details

I. General information

NPI: 1750895090
Provider Name (Legal Business Name): MIDWAY PHARMACY OF CLARKSON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 2ND ST
HENDERSON KY
42420-3364
US

IV. Provider business mailing address

408 E MAPLE ST PO BOX 607
CANEYVILLE KY
42721-9059
US

V. Phone/Fax

Practice location:
  • Phone: 270-212-1001
  • Fax: 855-782-5261
Mailing address:
  • Phone: 270-212-1001
  • Fax: 855-782-5261

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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP07865
License Number StateKY

VIII. Authorized Official

Name: TREVOR RAY
Title or Position: SECRETARY/OWNER
Credential:
Phone: 270-212-1001