Provider Demographics
NPI:1720818511
Name:FOUNTAIN SQUARE PHARMACY
Entity type:Organization
Organization Name:FOUNTAIN SQUARE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGLONE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:606-248-4444
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:606-248-4444
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:606-248-4444
Practice Address - Fax:606-248-6598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy