1962922435 NPI number — VANDERBILT HEALTH PHARMACY GROUP LLC

Table of content: (NPI 1962922435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962922435 NPI number — VANDERBILT HEALTH PHARMACY GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANDERBILT HEALTH PHARMACY GROUP 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:
VANDERBILT HEALTH PHARMACY GROUP
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:
1962922435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
718 MELROSE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37211-2151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-666-4992
Provider Business Mailing Address Fax Number:
615-242-1151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
718 MELROSE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37211-2151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-666-4992
Provider Business Practice Location Address Fax Number:
615-242-1151
Provider Enumeration Date:
06/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MANFRED
Authorized Official First Name:
JIM
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
615-322-4775

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PCN.0003470 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 6012 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 036.0134164 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 16879/7.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: NRP.022861300-03 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 2018004878 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: TN2291 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 0214002042 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 265500 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: NR-51511 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 64002467A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PHNR001396 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 054.020796 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PHA-MOP-LIC-52476 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: OSP.0007118 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q034038 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2170126 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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