MEDICARE: MADISON SOUTH PHARMACY LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	P07271	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1830808	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1386890952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON SOUTH PHARMACY LLC

Provider Business Mailing Address
First Line	:	40 MOONBOW PLZ
Second Line	:	STE 1
City	:	CORBIN
State	:	KY
Zip	:	40701-8982
Country	:	US
Telephone Number	:	606-258-0000
Fax Number	:	606-258-0003

Provider Business Practice Location Address
First Line	:	405 RICHMOND RD N
Second Line	:	STE D
City	:	BEREA
State	:	KY
Zip	:	40403-2083
Country	:	US
Telephone Number	:	859-228-0010
Fax Number	:	859-228-0014

Authorized Official
Title or Position	:	OWNER
Name	:	ERIC GIBBS
Credential	:
Telephone Number	:	606-258-0000

Provider Enumeration Date	:	08/14/2008
Last Update Date	:	08/02/2012

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