Provider Demographics
NPI:1265473144
Name:MT VERNON DRUG INC
Entity Type:Organization
Organization Name:MT VERNON DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:KILBOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-256-3447
Mailing Address - Street 1:410 RICHMOND ST
Mailing Address - Street 2:MT VERNON DRUG INC PO BOX 796
Mailing Address - City:MT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456
Mailing Address - Country:US
Mailing Address - Phone:606-256-3447
Mailing Address - Fax:606-256-8380
Practice Address - Street 1:410 RICHMOND ST
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456
Practice Address - Country:US
Practice Address - Phone:606-256-3447
Practice Address - Fax:606-256-8380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPO6536332B00000X
KYP06536333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54000286Medicaid
1310620001Medicare ID - Type Unspecified