Provider Demographics
NPI:1144386855
Name:PROFESSIONAL CARE SERVICES OF WEST TN INC
Entity Type:Organization
Organization Name:PROFESSIONAL CARE SERVICES OF WEST TN INC
Other - Org Name:SUSAN E INGRAM CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-622-1688
Mailing Address - Street 1:1997 HWY 51 S
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-3630
Mailing Address - Country:US
Mailing Address - Phone:901-476-8967
Mailing Address - Fax:901-313-1125
Practice Address - Street 1:5281 NAVY RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-2535
Practice Address - Country:US
Practice Address - Phone:901-873-0305
Practice Address - Fax:901-873-0306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38563336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4436350OtherNCPDP