Provider Demographics
NPI:1386890952
Name:MADISON SOUTH PHARMACY LLC
Entity type:Organization
Organization Name:MADISON SOUTH PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-258-0000
Mailing Address - Street 1:40 MOONBOW PLZ
Mailing Address - Street 2:STE 1
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-8982
Mailing Address - Country:US
Mailing Address - Phone:606-258-0000
Mailing Address - Fax:606-258-0003
Practice Address - Street 1:405 RICHMOND RD N
Practice Address - Street 2:STE D
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-2083
Practice Address - Country:US
Practice Address - Phone:859-228-0010
Practice Address - Fax:859-228-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KYP072713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1830808OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1830808OtherNCPDP PROVIDER IDENTIFICATION NUMBER