Provider Demographics
NPI:1629101852
Name:MAYFAIR PHARMACY INC
Entity Type:Organization
Organization Name:MAYFAIR PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER REGISTERED PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:E
Authorized Official - Last Name:REISZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-683-7379
Mailing Address - Street 1:2315 MAYFAIR SQUARE BLDG
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301
Mailing Address - Country:US
Mailing Address - Phone:270-683-7379
Mailing Address - Fax:270-926-6382
Practice Address - Street 1:2315 MAYFAIR SQUARE BLDG
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301
Practice Address - Country:US
Practice Address - Phone:270-683-7379
Practice Address - Fax:270-926-6382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP00480332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9008030000Medicaid
KY9008030000Medicaid