Provider Demographics
NPI:1225702632
Name:LANE, MATEASHA LEONA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATEASHA
Middle Name:LEONA
Last Name:LANE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 FERRY ST
Mailing Address - Street 2:
Mailing Address - City:LOUDON
Mailing Address - State:TN
Mailing Address - Zip Code:37774-1156
Mailing Address - Country:US
Mailing Address - Phone:865-809-1295
Mailing Address - Fax:
Practice Address - Street 1:929 NEW HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874-2726
Practice Address - Country:US
Practice Address - Phone:423-351-1277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist