Healthcare Provider Details

I. General information

NPI: 1679660823
Provider Name (Legal Business Name): CENTRAL CITY CLINIC PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 05/16/2020
Certification Date: 05/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N 2ND ST
CENTRAL CITY KY
42330-1205
US

IV. Provider business mailing address

203 N 2ND ST
CENTRAL CITY KY
42330-1205
US

V. Phone/Fax

Practice location:
  • Phone: 270-754-4300
  • Fax: 270-754-9881
Mailing address:
  • Phone: 270-754-4300
  • Fax: 270-754-9881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP00339
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SHANE FOGLE
Title or Position: PIC
Credential: RPH
Phone: 270-754-4300