Basic Information
Provider Information | |||||||||
NPI: | 1033661749 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARCUM & WALLACE MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARCUM & WALLACE MEMORIAL HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 60 MERCY CT | ||||||||
Address2: | PO BOX 928 | ||||||||
City: | IRVINE | ||||||||
State: | KY | ||||||||
PostalCode: | 403361331 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6067262146 | ||||||||
FaxNumber: | 6067232951 | ||||||||
Practice Location | |||||||||
Address1: | 60 MERCY CT | ||||||||
Address2: |   | ||||||||
City: | IRVINE | ||||||||
State: | KY | ||||||||
PostalCode: | 403361331 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6067262146 | ||||||||
FaxNumber: | 6067232951 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2016 | ||||||||
LastUpdateDate: | 10/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SPILLE | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SYSTEM DIRECTOR, RETAIL PHARMACY | ||||||||
AuthorizedOfficialTelephone: | 5139525063 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X |   |   | N |   | Suppliers | Pharmacy | Clinic Pharmacy | 333600000X | 05150 | KY | Y |   | Suppliers | Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 2163935 | 01 |   | PK | OTHER |