Healthcare Provider Details

I. General information

NPI: 1386377711
Provider Name (Legal Business Name): COURTNEY CHANTAL PRUITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2022
Last Update Date: 07/04/2022
Certification Date: 07/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4209 N MAYO TRL
PIKEVILLE KY
41501-3210
US

IV. Provider business mailing address

474 PONDEROSA DR
PAINTSVILLE KY
41240-8558
US

V. Phone/Fax

Practice location:
  • Phone: 606-432-0331
  • Fax:
Mailing address:
  • Phone: 606-792-0824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number022813
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: