Organization
KV MEDICAL LLC.
Active
Other names
Broadway & Main Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
JUSTIN KICKLITER (PIC)
(423) 720-9777
Entity
Organization
Contact information
Practice address
136 E. BROADWAY, NEWPORT, TN 37821-2323
(423) 720-9777
(423) 720-9778
Mailing address
136 E. BROADWAY, NEWPORT, TN 37821-2323
(423) 720-9777
(423) 720-9778
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
—
—
3336C0004X
Compounding Pharmacy
—
—
3336M0002X
Mail Order Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6866
BROADWAY & MAIN LICENSE
TN
05
—
Q046150
—
TN
Enumeration date
01/04/2019
Last updated
07/08/2024
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