Provider Demographics
NPI:1447656400
Name:MEDTECH PHARMACY, LLC
Entity type:Organization
Organization Name:MEDTECH PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLING
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:502-423-7525
Mailing Address - Street 1:9900 SHELBYVILLE RD
Mailing Address - Street 2:STE 2B
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2937
Mailing Address - Country:US
Mailing Address - Phone:502-423-7525
Mailing Address - Fax:502-425-4934
Practice Address - Street 1:426 GALLIMORE DAIRY RD STE 100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-9548
Practice Address - Country:US
Practice Address - Phone:336-252-2640
Practice Address - Fax:336-285-7237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC121473336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1447656400Medicaid
7431350001Medicare NSC