=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972787885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIKELS DRIVE IN PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2007
-----------------------------------------------------
Last Update Date | 06/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1928 CUMBERLAND AVE
-----------------------------------------------------
City | MIDDLESBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40965-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-248-1052
-----------------------------------------------------
Fax | 606-248-6598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1928 CUMBERLAND AVE
-----------------------------------------------------
City | MIDDLESBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40965-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-248-1052
-----------------------------------------------------
Fax | 606-248-6598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MIKEL BYRNE
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 606-248-1052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | PO1111
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------