1881740272 NPI number — JIMMY MAX PETTIGREW AND JAMES B PETTIGREW

Table of content: (NPI 1881740272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881740272 NPI number — JIMMY MAX PETTIGREW AND JAMES B PETTIGREW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JIMMY MAX PETTIGREW AND JAMES B PETTIGREW
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:
PETTIGREW DRUGS
Provider Other Organization Name Type Code:
3
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:
1881740272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 409
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADAMSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38310-0409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-632-3118
Provider Business Mailing Address Fax Number:
731-632-0567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
139 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADAMSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38310-2203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-632-3118
Provider Business Practice Location Address Fax Number:
731-632-0567
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PETTIGREW
Authorized Official First Name:
JIMMY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PHARMACIST
Authorized Official Telephone Number:
731-632-3118

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  101 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2095053 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com