Provider Demographics
NPI:1629053905
Name:SCOTT COUNTY MEDICAL ARTS PHARMACY INC
Entity Type:Organization
Organization Name:SCOTT COUNTY MEDICAL ARTS PHARMACY INC
Other - Org Name:MEDICAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-752-2692
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-0346
Mailing Address - Country:US
Mailing Address - Phone:812-752-4226
Mailing Address - Fax:
Practice Address - Street 1:1366 N GARDNER ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7793
Practice Address - Country:US
Practice Address - Phone:812-752-4226
Practice Address - Fax:812-752-4056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60004480A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100301260Medicaid
2024275OtherPK
2024275OtherPK