Provider Demographics
NPI:1154487429
Name:PHIPPS PHARMACY INC
Entity Type:Organization
Organization Name:PHIPPS PHARMACY INC
Other - Org Name:PHIPPS PHARMACY #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:731-352-0820
Mailing Address - Street 1:205B HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-0820
Mailing Address - Fax:731-352-2848
Practice Address - Street 1:121 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BRUCETON
Practice Address - State:TN
Practice Address - Zip Code:38317-1819
Practice Address - Country:US
Practice Address - Phone:731-586-2931
Practice Address - Fax:731-352-2848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
TN01463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1455149Medicaid
4404644OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5526220002Medicare NSC