Healthcare Provider Details

I. General information

NPI: 1225393374
Provider Name (Legal Business Name): CELIA RENEE TACKETT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2012
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E ELKHORN ST
ELKHORN CITY KY
41522-8557
US

IV. Provider business mailing address

105 E ELKHORN ST
ELKHORN CITY KY
41522-8557
US

V. Phone/Fax

Practice location:
  • Phone: 606-754-0221
  • Fax: 606-754-0225
Mailing address:
  • Phone: 606-754-0221
  • Fax: 606-754-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number015482
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: