Provider Demographics
NPI:1467219055
Name:MIDWAY PHARMACY OF CLARKSON, INC
Entity Type:Organization
Organization Name:MIDWAY PHARMACY OF CLARKSON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:VANCE
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:270-259-8500
Mailing Address - Street 1:908 WALLACE AVENUE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1479
Mailing Address - Country:US
Mailing Address - Phone:270-259-8400
Mailing Address - Fax:844-607-4498
Practice Address - Street 1:908 WALLACE AVENUE
Practice Address - Street 2:SUITE 105
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1479
Practice Address - Country:US
Practice Address - Phone:270-259-8400
Practice Address - Fax:844-607-4498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy