=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316940885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST TOWNE PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2005
-----------------------------------------------------
Last Update Date | 07/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2755 W PARK DR
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-9058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-443-0909
-----------------------------------------------------
Fax | 270-443-5544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2755 W PARK DR
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-9058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-443-0909
-----------------------------------------------------
Fax | 270-443-5544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PIC
-----------------------------------------------------
Name | GRANT MATHIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-443-0909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | P07652
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------