1922106962 NPI number — MIKE SWAIM & VAN SWAIM & BOB

Table of content: (NPI 1922106962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922106962 NPI number — MIKE SWAIM & VAN SWAIM & BOB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIKE SWAIM & VAN SWAIM & BOB
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:
BOBS DISCOUNT PHARMACY
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:
1922106962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8720 HIGHWAY 22
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
DRESDEN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38225-4348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-364-2207
Provider Business Mailing Address Fax Number:
731-364-2173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8720 HIGHWAY 22
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
DRESDEN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38225-4348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-364-2207
Provider Business Practice Location Address Fax Number:
731-364-2173
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DANIEL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
731-364-2207

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 331 , 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: 4406030 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2095273 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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