Provider Demographics
NPI:1700885001
Name:MIKELS DRIVE IN PHARMACY INC
Entity Type:Organization
Organization Name:MIKELS DRIVE IN PHARMACY INC
Other - Org Name:FOUNTAIN SQUARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMD
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGLONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-248-1052
Mailing Address - Street 1:1928 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1231
Mailing Address - Country:US
Mailing Address - Phone:606-248-1052
Mailing Address - Fax:606-248-6598
Practice Address - Street 1:1928 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1231
Practice Address - Country:US
Practice Address - Phone:606-248-1052
Practice Address - Fax:606-248-6598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP077083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153658OtherPK
KY54011945Medicaid
TN4582114Medicaid
0764260001Medicare ID - Type Unspecified