Provider Demographics
NPI:1669652210
Name:MAIN STREET PHARMACY LLC
Entity Type:Organization
Organization Name:MAIN STREET PHARMACY LLC
Other - Org Name:MAIN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-258-0000
Mailing Address - Street 1:150 MAIN STREET PHARMACY
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456
Mailing Address - Country:US
Mailing Address - Phone:606-256-0475
Mailing Address - Fax:606-256-0421
Practice Address - Street 1:150 MAIN STREET PHARMACY
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456
Practice Address - Country:US
Practice Address - Phone:606-256-0475
Practice Address - Fax:606-256-0421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KYP072203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100037810Medicaid
1830416OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY7100014800Medicaid
KY7100014800Medicaid