Provider Demographics
NPI:1306015573
Name:NEWBAKER, CHRISTY R
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:R
Last Name:NEWBAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5047
Mailing Address - Country:US
Mailing Address - Phone:800-447-4095
Mailing Address - Fax:601-482-7490
Practice Address - Street 1:126 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWBERN
Practice Address - State:TN
Practice Address - Zip Code:38059-1527
Practice Address - Country:US
Practice Address - Phone:731-627-2221
Practice Address - Fax:731-627-6152
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000009489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3693618OtherMEDICARE PART B
62-1656453OtherTAX ID NUMBER