Provider Demographics
NPI:1023007697
Name:PAUL, JOHNNY (DPH)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:PAUL
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 126
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37166-1118
Mailing Address - Country:US
Mailing Address - Phone:615-597-7822
Mailing Address - Fax:615-597-1112
Practice Address - Street 1:516-B WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37166-0299
Practice Address - Country:US
Practice Address - Phone:615-597-7822
Practice Address - Fax:615-597-1112
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC006677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN150553OtherBC/BS
TN4427313OtherNCPDP
TN9449808Medicaid
TN3563964OtherTN MEDICAL ASSISTANCE PRO
TN1141090001Medicare ID - Type Unspecified