Provider Demographics
NPI:1073979522
Name:JEFF CITY PHARMACIST GROUP LLC DBA MD PHARMACY STORE 2
Entity Type:Organization
Organization Name:JEFF CITY PHARMACIST GROUP LLC DBA MD PHARMACY STORE 2
Other - Org Name:BUNCH MEDICAL, LLC DBA MD PHARMACY STORE 2
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:865-262-9777
Mailing Address - Street 1:657 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760
Mailing Address - Country:US
Mailing Address - Phone:865-262-9777
Mailing Address - Fax:865-262-9778
Practice Address - Street 1:657 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760
Practice Address - Country:US
Practice Address - Phone:865-262-9777
Practice Address - Fax:865-262-9778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
TN57203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157383OtherPK
TNQ033187Medicaid