Provider Demographics
NPI:1245779255
Name:DJB PHARMACY LLC
Entity Type:Organization
Organization Name:DJB PHARMACY LLC
Other - Org Name:DJB PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ODELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-252-8464
Mailing Address - Street 1:305 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-9724
Mailing Address - Country:US
Mailing Address - Phone:901-235-7188
Mailing Address - Fax:866-201-2293
Practice Address - Street 1:305 LAKE DR STE 1
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-9724
Practice Address - Country:US
Practice Address - Phone:901-235-7188
Practice Address - Fax:866-201-2293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-23
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN59503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167929OtherPK