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General NPI Number Information
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NPI Number | 1639114416
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Entity Type | Organization
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Legal Business Name | MEDICORP, INC
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Dates
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Enumeration Date | 06/17/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 2354 HIGHWAY 15
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City | WHITESBURG
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State | KY
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Zip | 41858-7413
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Country | US
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Telephone | 606-633-4435
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Fax | 606-633-4570
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Provider Business Mailing Address
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Address Line | 2354 HIGHWAY 15
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City | WHITESBURG
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State | KY
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Zip | 41858-7413
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Country | US
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Telephone | 606-633-4435
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Fax | 606-633-4570
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Authorized Official
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Title or Position | PRESIDENT/ PHARMACIST
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Name | MR. EARNEST J. WATTS
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Credential | R.PH.
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Telephone | 606-633-4435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | PO1472
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | P01472
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License Number State | KY
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