Healthcare Provider Details

I. General information

NPI: 1487972287
Provider Name (Legal Business Name): PENNY MEDICINEBEAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 SUNSET AVE
SMITHS GROVE KY
42171-8164
US

IV. Provider business mailing address

PO BOX 433 324 SUNSET AVE
SMITHS GROVE KY
42171-0433
US

V. Phone/Fax

Practice location:
  • Phone: 270-784-7079
  • Fax: 270-451-1200
Mailing address:
  • Phone: 270-784-7079
  • Fax: 270-451-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number3586
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number3585
License Number StateKY

VIII. Authorized Official

Name: MR. MICHAEL FUQUA MEDICINEBEAR
Title or Position: CO-OWNER
Credential: N/A
Phone: 270-784-7079