Provider Demographics
NPI:1174670129
Name:GEORG E HOOTON & ROBERT K GALLOWAY III PTR MANOR PHARMACY
Entity Type:Organization
Organization Name:GEORG E HOOTON & ROBERT K GALLOWAY III PTR MANOR PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:615-883-5522
Mailing Address - Street 1:4343 LEBANON PIKE
Mailing Address - Street 2:SUITE #100
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-1221
Mailing Address - Country:US
Mailing Address - Phone:615-883-5522
Mailing Address - Fax:615-885-0402
Practice Address - Street 1:4343 LEBANON PIKE
Practice Address - Street 2:SUITE #114
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-1221
Practice Address - Country:US
Practice Address - Phone:615-883-5169
Practice Address - Fax:615-889-9733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000688332B00000X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN68401Medicaid
TN68401Medicaid