1417048760 NPI number — MR. LARRY MICHAEL PROFFITT DPH

Table of content: MR. LARRY MICHAEL PROFFITT DPH (NPI 1417048760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417048760 NPI number — MR. LARRY MICHAEL PROFFITT DPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROFFITT
Provider First Name:
LARRY
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1417048760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 WEST G ST
Provider Second Line Business Mailing Address:
BURGIE DRUGSTORE LLC
Provider Business Mailing Address City Name:
ELIZABETHTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-542-4622
Provider Business Mailing Address Fax Number:
423-542-2564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 WEST G ST
Provider Second Line Business Practice Location Address:
BURGIE DRUGSTORE LLC
Provider Business Practice Location Address City Name:
ELIZABETHTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-542-4622
Provider Business Practice Location Address Fax Number:
423-542-2564
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  3208 , 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)





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