1952404063 NPI number — TIM WAYNE REAGAN PHARMD

Table of content: TIM WAYNE REAGAN PHARMD (NPI 1952404063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952404063 NPI number — TIM WAYNE REAGAN PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REAGAN
Provider First Name:
TIM
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
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:
1952404063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
563 EVERVILLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVINGSTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38570-6058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-510-7375
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8456 HIGHWAY 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BYRDSTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38549-6001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-864-3136
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2006

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:  21917 , 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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