Provider Demographics
NPI:1043612880
Name:PORTLAND PRESCRIPTION SHOP PLLC
Entity Type:Organization
Organization Name:PORTLAND PRESCRIPTION SHOP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:STINNETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-392-4248
Mailing Address - Street 1:705 S BROADWAY ST
Mailing Address - Street 2:P.O. BOX 910
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1628
Mailing Address - Country:US
Mailing Address - Phone:615-323-5050
Mailing Address - Fax:615-323-5052
Practice Address - Street 1:705 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1628
Practice Address - Country:US
Practice Address - Phone:615-323-5050
Practice Address - Fax:615-323-5052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
TN54513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty