1073979522 NPI number — JEFF CITY PHARMACIST GROUP LLC DBA MD PHARMACY STORE 2

Table of content: (NPI 1073979522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073979522 NPI number — JEFF CITY PHARMACIST GROUP LLC DBA MD PHARMACY STORE 2

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFF CITY PHARMACIST GROUP LLC DBA MD PHARMACY STORE 2
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:
BUNCH MEDICAL, LLC DBA MD PHARMACY STORE 2
Provider Other Organization Name Type Code:
4
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:
1073979522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
657 E BROADWAY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-262-9777
Provider Business Mailing Address Fax Number:
865-262-9778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
657 E BROADWAY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-262-9777
Provider Business Practice Location Address Fax Number:
865-262-9778
Provider Enumeration Date:
01/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BLAKE
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
865-262-9777

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X , with the licence number: 5720 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2157383 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: Q033187 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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