Provider Demographics
NPI:1063553345
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:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:DARREL
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:270-476-3600
Mailing Address - Street 1:3901 U.S. HWY 41 S.
Mailing Address - Street 2:
Mailing Address - City:BEECHMONT
Mailing Address - State:KY
Mailing Address - Zip Code:42323
Mailing Address - Country:US
Mailing Address - Phone:270-476-3600
Mailing Address - Fax:270-476-3100
Practice Address - Street 1:3901 US HWY 41 S
Practice Address - Street 2:
Practice Address - City:BEECHMONT
Practice Address - State:KY
Practice Address - Zip Code:42323
Practice Address - Country:US
Practice Address - Phone:270-476-3600
Practice Address - Fax:270-476-3100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1824475OtherNABP #
KY54032167Medicaid
KY54032167Medicaid
KY0290230003Medicare ID - Type UnspecifiedMEDICARE