Provider Demographics
NPI:1205189487
Name:DEARTH, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DEARTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 STONEBROOK PL
Mailing Address - Street 2:T-0921
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:535 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-2536
Practice Address - Country:US
Practice Address - Phone:731-989-0077
Practice Address - Fax:731-989-0076
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist