Provider Demographics
NPI:1730285545
Name:MT. VERNON DRUG, INC.
Entity Type:Organization
Organization Name:MT. VERNON DRUG, INC.
Other - Org Name:STANFORD DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:STIGALL
Authorized Official - Last Name:GRUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:606-365-2100
Mailing Address - Street 1:PO BOX 364
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-0364
Mailing Address - Country:US
Mailing Address - Phone:606-365-2100
Mailing Address - Fax:606-365-4153
Practice Address - Street 1:107 METKER TRL STE D
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-1049
Practice Address - Country:US
Practice Address - Phone:606-365-2100
Practice Address - Fax:606-365-4153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP06743332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54003157Medicaid
KY90006503Medicaid
KYBS7648441OtherDEA
KY1310620002Medicare NSC