Provider Demographics
NPI:1073682852
Name:MCDONALD PHARMACY INC
Entity Type:Organization
Organization Name:MCDONALD PHARMACY INC
Other - Org Name:MCDONALD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:STULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-922-5512
Mailing Address - Street 1:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:SOUTH SHORE
Mailing Address - State:KY
Mailing Address - Zip Code:41175-0774
Mailing Address - Country:US
Mailing Address - Phone:606-932-3614
Mailing Address - Fax:
Practice Address - Street 1:437 JAMES E HANNAH DR
Practice Address - Street 2:
Practice Address - City:SOUTH SHORE
Practice Address - State:KY
Practice Address - Zip Code:41175-9600
Practice Address - Country:US
Practice Address - Phone:606-932-3614
Practice Address - Fax:606-932-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP010703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2029133OtherPK
OH0391517Medicaid
KY54014196Medicaid
0960910001Medicare NSC