1285793653 NPI number — MARKS PHARMACY

Table of content: (NPI 1285793653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285793653 NPI number — MARKS PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARKS PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285793653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1035
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37769-1035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-300-8084
Provider Business Mailing Address Fax Number:
865-426-9200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 CREEK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-426-2186
Provider Business Practice Location Address Fax Number:
865-426-9200
Provider Enumeration Date:
12/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
865-426-2186

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  1352 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3910029 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4408173 . This is a "NCPDP-PHARMACY" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4440412 . This is a "NCPDP-DME" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".