Provider Demographics
NPI:1750895090
Name:MIDWAY PHARMACY OF CLARKSON INC
Entity type:Organization
Organization Name:MIDWAY PHARMACY OF CLARKSON INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-212-1001
Mailing Address - Street 1:408 E MAPLE ST
Mailing Address - Street 2:PO BOX 607
Mailing Address - City:CANEYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42721-9059
Mailing Address - Country:US
Mailing Address - Phone:270-212-1001
Mailing Address - Fax:855-782-5261
Practice Address - Street 1:1640 2ND ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-3364
Practice Address - Country:US
Practice Address - Phone:270-212-1001
Practice Address - Fax:855-782-5261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
KYP078653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100504950Medicaid
2174033OtherPK