Healthcare Provider Details

I. General information

NPI: 1699721720
Provider Name (Legal Business Name): ISOM COMMUNITY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 ISOM PLAZA
ISOM KY
41824-9011
US

IV. Provider business mailing address

PO BOX 250 93 ISOM PLAZA
ISOM KY
41824-0250
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-9238
  • Fax:
Mailing address:
  • Phone: 606-633-9238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberP06559
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP06559
License Number StateKY

VIII. Authorized Official

Name: SCOTT E. BURRIS
Title or Position: PHARMACIST
Credential: RPH
Phone: 606-633-9238