Provider Demographics
NPI:1386377711
Name:PRUITT, COURTNEY CHANTAL
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:CHANTAL
Last Name:PRUITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-8558
Mailing Address - Country:US
Mailing Address - Phone:606-792-0824
Mailing Address - Fax:
Practice Address - Street 1:4209 N MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3210
Practice Address - Country:US
Practice Address - Phone:606-432-0331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist