Provider Demographics
NPI:1396852307
Name:EPHRAIM MCDOWELL LIBERTY PHARMACY
Entity Type:Organization
Organization Name:EPHRAIM MCDOWELL LIBERTY PHARMACY
Other - Org Name:WELLNESS FIRST PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF PHARMACY SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:HALTOM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:859-239-1721
Mailing Address - Street 1:217 SOUTH THIRD STREET
Mailing Address - Street 2:DEPT OF PHARMACY
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-8911
Mailing Address - Country:US
Mailing Address - Phone:859-239-1721
Mailing Address - Fax:
Practice Address - Street 1:68 HUSTONVILLE STREET
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3456
Practice Address - Country:US
Practice Address - Phone:859-239-1721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KYP070293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54011507Medicaid