Provider Demographics
NPI:1205967395
Name:CENTRAL CITY CLINIC PHARMACY, INC.
Entity type:Organization
Organization Name:CENTRAL CITY CLINIC PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GENTRY
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:42330-1287
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:42330-1287
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:2007-03-08
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1804031OtherNABP
KY0290230001OtherMEDICARE
KY90040890Medicaid
KYP00339OtherSTORE PERMIT #