Organization
MIDTOWN PHARMACY EXPRESS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHNATHAN FULLER PHARM.D. (OWNER)
(270) 274-9224
Entity
Organization
Contact information
Practice address
500 N MAIN ST, BEAVER DAM, KY 42320-1949
(270) 274-9224
(270) 274-9226
Mailing address
500 N MAIN ST, P.O. BOX 125, BEAVER DAM, KY 42320-1949
(270) 274-9224
(270) 274-9226
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
P07565
KY
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7100238220
—
KY
01
—
P07565
PHARMACY LICENSE
KY
Enumeration date
04/04/2013
Last updated
11/20/2013
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