Provider Demographics
NPI:1275622961
Name:OLDE TOWNE PHARMACY INC
Entity Type:Organization
Organization Name:OLDE TOWNE PHARMACY INC
Other - Org Name:OLDE TOWNE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:NOLEN
Authorized Official - Last Name:CLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-753-4446
Mailing Address - Street 1:102 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-1224
Mailing Address - Country:US
Mailing Address - Phone:423-753-4446
Mailing Address - Fax:423-753-4587
Practice Address - Street 1:102 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-1224
Practice Address - Country:US
Practice Address - Phone:423-753-4446
Practice Address - Fax:423-753-4587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN19803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4424367OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TN9449461Medicaid
TN9449461Medicaid