Healthcare Provider Details

I. General information

NPI: 1497348072
Provider Name (Legal Business Name): MR. EVERETT LANE DUNAWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 HIGHWAY 15 S
JACKSON KY
41339-7370
US

IV. Provider business mailing address

377 SNOWDEN BRANCH RD
JACKSON KY
41339-7496
US

V. Phone/Fax

Practice location:
  • Phone: 606-666-5519
  • Fax: 606-666-9371
Mailing address:
  • Phone: 606-548-1953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number10619
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: