Provider Demographics
NPI:1265584023
Name:M.T.O. PHARMACY, INC
Entity type:Organization
Organization Name:M.T.O. PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:OVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-337-2336
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:121 VIRGINIA AVE., SUITE E100
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-0507
Mailing Address - Country:US
Mailing Address - Phone:606-337-2336
Mailing Address - Fax:606-337-1419
Practice Address - Street 1:121 W VIRGINIA AVE STE E100
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1600
Practice Address - Country:US
Practice Address - Phone:606-337-2336
Practice Address - Fax:606-337-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPO20553336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54022447Medicaid
KY90200072Medicaid
KY0655850001Medicare ID - Type Unspecified