Provider Demographics
NPI:1336287424
Name:SIGNAL MOUNTAIN PHARMACY, LLC.
Entity Type:Organization
Organization Name:SIGNAL MOUNTAIN PHARMACY, LLC.
Other - Org Name:SIGNAL MOUNTAIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RODERICK (RICK)
Authorized Official - Middle Name:ADAMS
Authorized Official - Last Name:GALLAHER
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:423-886-2135
Mailing Address - Street 1:804 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-3065
Mailing Address - Country:US
Mailing Address - Phone:423-886-2135
Mailing Address - Fax:423-886-6035
Practice Address - Street 1:804 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:SIGNAL MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37377-3065
Practice Address - Country:US
Practice Address - Phone:423-886-2135
Practice Address - Fax:423-886-6035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ046083Medicaid