Organization
PEYTLIV INC
Active
Other names
Crater City Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
DETRA ROBERTSON (PHARMACIST/OWNER)
(606) 248-9330
Entity
Organization
Contact information
Practice address
915 N BROAD ST, NEW TAZEWELL, TN 37825-6633
(423) 626-5511
Mailing address
1841 N 25TH ST, MIDDLESBORO, KY 40965-1853
(606) 248-9330
(606) 248-9337
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PO7862
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2177440
PK
—
Enumeration date
05/10/2018
Last updated
09/19/2025
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