Provider Demographics
NPI:1346740479
Name:GAGNE, ADAM PAUL
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:PAUL
Last Name:GAGNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ROCKY BOTTOM DR
Mailing Address - Street 2:
Mailing Address - City:UNICOI
Mailing Address - State:TN
Mailing Address - Zip Code:37692-4030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 ROCKY BOTTOM DR
Practice Address - Street 2:
Practice Address - City:UNICOI
Practice Address - State:TN
Practice Address - Zip Code:37692-4030
Practice Address - Country:US
Practice Address - Phone:423-743-9998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist