Provider Demographics
NPI:1225166440
Name:EDMONSON DRUG COMPANY INC
Entity Type:Organization
Organization Name:EDMONSON DRUG COMPANY INC
Other - Org Name:EDMONSON DRUG CO.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:270-597-2386
Mailing Address - Street 1:100 PARK PLACE , STE 8
Mailing Address - Street 2:PO BOX 58
Mailing Address - City:BROWNSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42210-0058
Mailing Address - Country:US
Mailing Address - Phone:270-597-2386
Mailing Address - Fax:844-682-8099
Practice Address - Street 1:100 PARK PLACE, STE 8
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42210-0058
Practice Address - Country:US
Practice Address - Phone:270-597-2386
Practice Address - Fax:844-682-8099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWAY PHARMACY OF CLARKSON, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-01
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP07681332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9002031400Medicaid
KY9002031400Medicaid