Provider Demographics
NPI:1487972287
Name:PENNY MEDICINEBEAR
Entity type:Organization
Organization Name:PENNY MEDICINEBEAR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:FUQUA
Authorized Official - Last Name:MEDICINEBEAR
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:270-784-7079
Mailing Address - Street 1:PO BOX 433
Mailing Address - Street 2:324 SUNSET AVE
Mailing Address - City:SMITHS GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42171-0433
Mailing Address - Country:US
Mailing Address - Phone:270-784-7079
Mailing Address - Fax:270-451-1200
Practice Address - Street 1:324 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:SMITHS GROVE
Practice Address - State:KY
Practice Address - Zip Code:42171-8164
Practice Address - Country:US
Practice Address - Phone:270-784-7079
Practice Address - Fax:270-451-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3586344600000X
KY3585344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi