=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659671428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMETOWN PHARMACY OF CYNTHIANA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2010
-----------------------------------------------------
Last Update Date | 02/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1134 US HWY 27 SOUTH
-----------------------------------------------------
City | CYNTHIANA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41031-7570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-234-5600
-----------------------------------------------------
Fax | 859-234-5606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1134 US HWY 27 SOUTH
-----------------------------------------------------
City | CYNTHIANA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41031-7570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-234-5600
-----------------------------------------------------
Fax | 859-234-5606
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL ALLEN INGRAM
-----------------------------------------------------
Credential | PHARM.D
-----------------------------------------------------
Telephone | 859-234-5600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | PENDING
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PENDING
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------