Healthcare Provider Details

I. General information

NPI: 1508114463
Provider Name (Legal Business Name): SOUTH DIXIE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12134 SOUTH DIXIE HIGHWAY
SONORA KY
42776
US

IV. Provider business mailing address

12134 SOUTH DIXIE HIGHWAY
SONORA KY
42776
US

V. Phone/Fax

Practice location:
  • Phone: 270-949-3494
  • Fax: 270-949-3494
Mailing address:
  • Phone: 270-949-3494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP07531
License Number StateKY

VIII. Authorized Official

Name: DR. MATTHEW W DANIELS
Title or Position: CO-OWNER/PHARMACIST
Credential: PHARMD
Phone: 270-949-3494