Provider Demographics
NPI:1699395467
Name:SOUTH DIXIE PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTH DIXIE PHARMACY LLC
Other - Org Name:SOUTH DIXIE PHARMACY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-949-3494
Mailing Address - Street 1:12134 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:KY
Mailing Address - Zip Code:42776-9739
Mailing Address - Country:US
Mailing Address - Phone:270-949-3494
Mailing Address - Fax:
Practice Address - Street 1:12134 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:KY
Practice Address - Zip Code:42776-9739
Practice Address - Country:US
Practice Address - Phone:270-949-3494
Practice Address - Fax:270-949-3494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-22
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100217350Medicaid