Healthcare Provider Details

I. General information

NPI: 1669652210
Provider Name (Legal Business Name): MAIN STREET PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MAIN STREET PHARMACY
MT VERNON KY
40456
US

IV. Provider business mailing address

150 MAIN STREET PHARMACY
MT VERNON KY
40456
US

V. Phone/Fax

Practice location:
  • Phone: 606-256-0475
  • Fax: 606-256-0421
Mailing address:
  • Phone: 606-256-0475
  • Fax: 606-256-0421

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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP07220
License Number StateKY

VIII. Authorized Official

Name: ERIC GIBBS
Title or Position: OWNER
Credential:
Phone: 606-258-0000