1043364490 NPI number — MOUNTAIN VALLEY RX 05 INC

Table of content: (NPI 1043364490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043364490 NPI number — MOUNTAIN VALLEY RX 05 INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN VALLEY RX 05 INC
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:
1043364490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 385
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANDRIDGE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37725-0385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-475-9969
Provider Business Mailing Address Fax Number:
865-475-9901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
153 E BROADWAY BLVD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37760-2517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-471-5111
Provider Business Practice Location Address Fax Number:
865-471-5199
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KISABETH
Authorized Official First Name:
BEAU
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
865-388-3211

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 3918 , 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: 4437364 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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