Provider Demographics
NPI:1073835369
Name:PEVAHOUSE, WILLIAM RUSSELL (DPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:RUSSELL
Last Name:PEVAHOUSE
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 1:102 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-3327
Mailing Address - Country:US
Mailing Address - Phone:615-446-3922
Mailing Address - Fax:
Practice Address - Street 1:301 HENSLEE DR
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2050
Practice Address - Country:US
Practice Address - Phone:615-446-7485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-27
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist