Provider Demographics
NPI:1225472343
Name:CIA DRUG LLC
Entity Type:Organization
Organization Name:CIA DRUG LLC
Other - Org Name:HOLBROOK DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-784-4784
Mailing Address - Street 1:208 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1620
Mailing Address - Country:US
Mailing Address - Phone:606-784-4784
Mailing Address - Fax:606-784-5858
Practice Address - Street 1:208 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1620
Practice Address - Country:US
Practice Address - Phone:606-784-4784
Practice Address - Fax:606-784-5858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP075633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140051OtherPK
KY7100245100Medicaid
7060150001Medicare NSC