1821362526 NPI number — FOUNTAIN PLAZA PHARMACY LLC

Table of content: (NPI 1821362526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821362526 NPI number — FOUNTAIN PLAZA PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNTAIN PLAZA PHARMACY 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:
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:
1821362526
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2825 W ANDREW JOHNSON HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRISTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37814-3216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-307-5757
Provider Business Mailing Address Fax Number:
423-307-5241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2825 W ANDREW JOHNSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORRISTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-307-5757
Provider Business Practice Location Address Fax Number:
423-307-5241
Provider Enumeration Date:
02/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HUNTSMAN
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER & CFO
Authorized Official Telephone Number:
423-736-7976

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2018008256 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: OSP.0006973 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054.020619 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 14556 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: TN1923 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHNR001097 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 4998 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 4998 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 4998 , 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: 7Z1164 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95213 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1821362526 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2134355 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4067029 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300047862 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431597 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2018228689 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 574038 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100373620 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000202940 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 232282407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7Z1164 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q035892 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103955980001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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