Provider Demographics
NPI:1366170243
Name:FERGUSON, BREANNA PAIGE (PHARMD)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:PAIGE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PHARMD
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 451
Mailing Address - Street 2:
Mailing Address - City:FLAT LICK
Mailing Address - State:KY
Mailing Address - Zip Code:40935-0451
Mailing Address - Country:US
Mailing Address - Phone:606-499-5170
Mailing Address - Fax:
Practice Address - Street 1:515 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1131
Practice Address - Country:US
Practice Address - Phone:606-248-2093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYF11-121-310OtherDRIVERS LICENSE