=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114311818
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PET360
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2015
-----------------------------------------------------
Last Update Date | 03/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2815 WATTERSON TRL
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40299-3868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-977-3879
-----------------------------------------------------
Fax | 866-253-0274
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2815 WATTERSON TRL
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40299-3868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-977-3879
-----------------------------------------------------
Fax | 866-253-0274
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | DR. JUSTIN MILLS
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 502-716-7301
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336M0002X
-----------------------------------------------------
Taxonomy Name | Mail Order Pharmacy
-----------------------------------------------------
License Number | P07651
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------