Provider Demographics
NPI:1902349996
Name:PHARMACY CARE CENTERS CLINIC LLC
Entity Type:Organization
Organization Name:PHARMACY CARE CENTERS CLINIC LLC
Other - Org Name:PHARMACY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-435-0460
Mailing Address - Street 1:101 TOWN AND COUNTRY LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9524
Mailing Address - Country:US
Mailing Address - Phone:606-439-1300
Mailing Address - Fax:606-439-0778
Practice Address - Street 1:101 TOWN AND COUNTRY LN
Practice Address - Street 2:SUITE 101
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9524
Practice Address - Country:US
Practice Address - Phone:606-439-1300
Practice Address - Fax:606-439-0778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-23
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP07817333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166475OtherPK