1184983561 NPI number — GUARDIAN PHARMACY OF TENNESSEE TWO, LLC

Table of content: (NPI 1184983561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184983561 NPI number — GUARDIAN PHARMACY OF TENNESSEE TWO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF TENNESSEE TWO, LLC
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:
6
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:
1184983561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT #2393 GUARDIAN PHARMACY OF TENNESSEE TWO
Provider Second Line Business Mailing Address:
P.O. BOX 11407
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-810-0089
Provider Business Mailing Address Fax Number:
404-810-0094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7657 US HIGHWAY 70
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARTLETT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38133-2054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-800-2100
Provider Business Practice Location Address Fax Number:
855-885-0612
Provider Enumeration Date:
05/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
931-684-9987

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 0000004997 , 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: 201639407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2135066 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1184983561 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00326567 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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