1578066072 NPI number — CENTRAL CITY CLINIC PHARMACY, INC.

Table of content: (NPI 1578066072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578066072 NPI number — CENTRAL CITY CLINIC PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL CITY CLINIC PHARMACY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578066072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 N 2ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRAL CITY
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42330-1205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-754-4300
Provider Business Mailing Address Fax Number:
270-754-9881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 RUBY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISONVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42431-2168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-754-4300
Provider Business Practice Location Address Fax Number:
270-754-9881
Provider Enumeration Date:
03/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIOTT
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
POWERS
Authorized Official Title or Position:
CPA
Authorized Official Telephone Number:
270-684-3414

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  P07870 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P07870 . This is a "PHARMACY PERMIT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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