{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
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"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
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"Credential": null,
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"OtherLastName": null,
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"FirstLineMailingAddress": "500 N MAIN ST",
"SecondLineMailingAddress": "P.O. BOX 125",
"MailingAddressCityName": "BEAVER DAM",
"MailingAddressStateName": "KY",
"MailingAddressPostalCode": "42320-1949",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "270-274-9224",
"MailingAddressFaxNumber": "270-274-9226",
"FirstLinePracticeLocationAddress": "500 N MAIN ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "BEAVER DAM",
"PracticeLocationAddressStateName": "KY",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "270-274-9224",
"PracticeLocationAddressFaxNumber": "270-274-9226",
"EnumerationDate": "04/04/2013",
"LastUpdateDate": "11/20/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FULLER",
"AuthorizedOfficialFirstName": "JOHNATHAN",
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"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "PHARM.D.",
"AuthorizedOfficialTelephoneNumber": "270-274-9224",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "3336C0004X",
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"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "332B00000X",
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},
{
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "P07565",
"LicenseNumberStateCode": "KY",
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}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}