Provider Demographics
NPI:1033254552
Name:HAYNES, GERALD WAYNE (DPH)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:WAYNE
Last Name:HAYNES
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 1:3631 BROOKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-5810
Mailing Address - Country:US
Mailing Address - Phone:931-432-4437
Mailing Address - Fax:
Practice Address - Street 1:1200 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-4157
Practice Address - Country:US
Practice Address - Phone:931-432-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist