Provider Demographics
NPI:1093982621
Name:SOUTHERRN HOME INFUSION PHARMACY
Entity Type:Organization
Organization Name:SOUTHERRN HOME INFUSION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:COWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:865-674-6700
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:1721 MAIN STREET
Mailing Address - City:WHITE PINE
Mailing Address - State:TN
Mailing Address - Zip Code:37890
Mailing Address - Country:US
Mailing Address - Phone:865-674-6700
Mailing Address - Fax:865-674-6704
Practice Address - Street 1:1721 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WHITE PINE
Practice Address - State:TN
Practice Address - Zip Code:37890
Practice Address - Country:US
Practice Address - Phone:865-674-6700
Practice Address - Fax:865-674-6704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2342332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1168140001Medicare NSC