1306283072 NPI number — GUARDIAN PHARMACY OF KNOXVILLE LLC

Table of content: (NPI 1306283072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306283072 NPI number — GUARDIAN PHARMACY OF KNOXVILLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF KNOXVILLE 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:
EAST TENNESSEE PHARMACY SERVICES
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:
1306283072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
GUARDIAN PHARMACY OF TENNESSEE ONE DEPT 2441
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:
431 PARK VILLAGE RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37923-3849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-730-4200
Provider Business Practice Location Address Fax Number:
865-730-4201
Provider Enumeration Date:
06/04/2013

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: 5188 , 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: 1306283072 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200642900A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1306283072 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1306283072 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142751200 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2140656 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1306283072 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810030160 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 70100257410 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7T5188 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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