Healthcare Provider Details

I. General information

NPI: 1669071619
Provider Name (Legal Business Name): TED SERVER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

3101 RICHMOND RD
LEXINGTON KY
40509-1599
US

IV. Provider business mailing address

904 WESTCHESTER WAY
RICHMOND KY
40475-8893
US

V. Phone/Fax

Practice location:
  • Phone: 859-268-6006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number017881
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: