Provider Demographics
NPI:1932442266
Name:MIDTOWN PHARMACY EXPRESS, LLC
Entity Type:Organization
Organization Name:MIDTOWN PHARMACY EXPRESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:270-274-9224
Mailing Address - Street 1:500 N MAIN ST
Mailing Address - Street 2:P.O. BOX 125
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-1949
Mailing Address - Country:US
Mailing Address - Phone:270-274-9224
Mailing Address - Fax:270-274-9226
Practice Address - Street 1:500 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-1949
Practice Address - Country:US
Practice Address - Phone:270-274-9224
Practice Address - Fax:270-274-9226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
KYP075653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP07565OtherPHARMACY LICENSE
KY7100238220Medicaid
KY7100238220Medicaid
KYP07565OtherPHARMACY LICENSE