MEDICARE: WEST TOWNE PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	P07652	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2148441	OTHER		PK

General Provider Information

NPI Number	:	1316940885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST TOWNE PHARMACY INC

Provider Business Mailing Address
First Line	:	2755 W PARK DR
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42001-9058
Country	:	US
Telephone Number	:	270-443-0909
Fax Number	:	270-443-5544

Provider Business Practice Location Address
First Line	:	2755 W PARK DR
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42001-9058
Country	:	US
Telephone Number	:	270-443-0909
Fax Number	:	270-443-5544

Authorized Official
Title or Position	:	OWNER/PIC
Name	:	GRANT MATHIS
Credential	:
Telephone Number	:	270-443-0909

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	07/01/2015

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