Provider Demographics
NPI:1275530891
Name:MCMINNVILLE DRUG CENTER INC
Entity Type:Organization
Organization Name:MCMINNVILLE DRUG CENTER INC
Other - Org Name:MCMINNVILLE DRUG CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-473-4471
Mailing Address - Street 1:1500 SPARTA ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1317
Mailing Address - Country:US
Mailing Address - Phone:931-473-4471
Mailing Address - Fax:931-473-2217
Practice Address - Street 1:1500 SPARTA ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1317
Practice Address - Country:US
Practice Address - Phone:931-473-4471
Practice Address - Fax:931-473-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-29
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TN000001453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4415318OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TN3533833Medicaid
TN3533833Medicaid