1982130290 NPI number — PHARMACY AT FAMILY MEDICAL CENTER PLLC

Table of content: (NPI 1982130290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982130290 NPI number — PHARMACY AT FAMILY MEDICAL CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMACY AT FAMILY MEDICAL CENTER PLLC
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:
THE PHARMACY AT FAMILY MEDICAL CENTER PLLC
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:
1982130290
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:
300 N CONGRESS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMITHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37166-2704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-215-6979
Provider Business Mailing Address Fax Number:
615-597-6337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 N CONGRESS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37166-2704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-215-6979
Provider Business Practice Location Address Fax Number:
615-597-6337
Provider Enumeration Date:
05/05/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DAUGHTRY
Authorized Official First Name:
SUSANNAH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
615-215-6979

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: 0000006174 , 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: 2175748 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: Q034972 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com