Provider Demographics
NPI:1841574555
Name:SPECIALTY CARE CENTERS OF EASTERN KENTUCKY
Entity Type:Organization
Organization Name:SPECIALTY CARE CENTERS OF EASTERN KENTUCKY
Other - Org Name:VICCO PRESCRIPTION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-251-3931
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:VICCO
Mailing Address - State:KY
Mailing Address - Zip Code:41773-0189
Mailing Address - Country:US
Mailing Address - Phone:606-476-2333
Mailing Address - Fax:606-476-2082
Practice Address - Street 1:10897 S HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:SCUDDY
Practice Address - State:KY
Practice Address - Zip Code:41760-9033
Practice Address - Country:US
Practice Address - Phone:606-476-2333
Practice Address - Fax:606-476-2082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP074733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100178780Medicaid
2131977OtherPK