Provider Demographics
NPI:1679660823
Name:CENTRAL CITY CLINIC PHARMACY INC
Entity Type:Organization
Organization Name:CENTRAL CITY CLINIC PHARMACY INC
Other - Org Name:CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGLE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-754-4300
Mailing Address - Street 1:203 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42330-1205
Mailing Address - Country:US
Mailing Address - Phone:270-754-4300
Mailing Address - Fax:270-754-9881
Practice Address - Street 1:203 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:KY
Practice Address - Zip Code:42330-1205
Practice Address - Country:US
Practice Address - Phone:270-754-4300
Practice Address - Fax:270-754-9881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0002X, 3336C0004X
KYP003393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54012455Medicaid
2028602OtherPK
KY54012455Medicaid
0290230001Medicare NSC