Provider Demographics
NPI:1437172418
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:OWNER/SECRETARY
Authorized Official - Prefix:
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:PO BOX 58
Mailing Address - Street 2:
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
KYP076813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2028554OtherPK
KY7100384270Medicaid
0926490001Medicare NSC
0926490001Medicare NSC