Provider Demographics
NPI:1689662108
Name:PRATER, DAVID STEWART JR (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:STEWART
Last Name:PRATER
Suffix:JR
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:KY
Mailing Address - Zip Code:42041-1544
Mailing Address - Country:US
Mailing Address - Phone:270-472-2984
Mailing Address - Fax:270-472-9377
Practice Address - Street 1:208 LAKE ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:KY
Practice Address - Zip Code:42041-1544
Practice Address - Country:US
Practice Address - Phone:270-472-2984
Practice Address - Fax:270-472-9377
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90005596Medicaid
KY90005596Medicaid