Provider Demographics
NPI:1861468472
Name:FORTENBERRY, LARRY T (RPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:T
Last Name:FORTENBERRY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 734
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0734
Mailing Address - Country:US
Mailing Address - Phone:606-432-6860
Mailing Address - Fax:
Practice Address - Street 1:95 WEDDINGTON BRANCH RD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3203
Practice Address - Country:US
Practice Address - Phone:606-432-2424
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist