Provider Demographics
NPI:1124399738
Name:PARKWAY PHARMACY, INC.
Entity Type:Organization
Organization Name:PARKWAY PHARMACY, INC.
Other - Org Name:PARKWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-226-4444
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:SALYERSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41465-0008
Mailing Address - Country:US
Mailing Address - Phone:606-349-4400
Mailing Address - Fax:606-349-4410
Practice Address - Street 1:100 BRENNA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SALYERSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41465-9815
Practice Address - Country:US
Practice Address - Phone:606-349-4400
Practice Address - Fax:606-349-4410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP074883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100193170Medicaid
2133434OtherPK