=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396852307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EPHRAIM MCDOWELL LIBERTY PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 04/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 68 HUSTONVILLE STREET
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42539-3456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-239-1721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 217 SOUTH THIRD STREET DEPT OF PHARMACY
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40422-8911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-239-1721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PHARMACY SERVICES
-----------------------------------------------------
Name | DR. JOAN B HALTOM
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 859-239-1721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | P07029
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------