Provider Demographics
NPI:1164563896
Name:LA VERGNE DRUG INC
Entity Type:Organization
Organization Name:LA VERGNE DRUG INC
Other - Org Name:LA VERGNE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:615-213-1203
Mailing Address - Street 1:PO BOX 1358
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-1358
Mailing Address - Country:US
Mailing Address - Phone:615-213-1203
Mailing Address - Fax:615-213-1530
Practice Address - Street 1:5148B MURFREESBORO RD
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-2712
Practice Address - Country:US
Practice Address - Phone:615-213-1203
Practice Address - Fax:615-213-1530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN332B00000X
TN3988333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies