Provider Demographics
NPI:1952402992
Name:CEDAR TRACE PHARMACY, INC.
Entity type:Organization
Organization Name:CEDAR TRACE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-432-2424
Mailing Address - Street 1:95 WEDDINGTON BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3203
Mailing Address - Country:US
Mailing Address - Phone:606-432-2424
Mailing Address - Fax:606-432-2454
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:606-432-2454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KYP068503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54004486Medicaid
KY4966510001Medicare ID - Type UnspecifiedMEDICARE