Provider Demographics
NPI:1356475040
Name:CHRISTIAN, CHARLES JEFFERY (DPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JEFFERY
Last Name:CHRISTIAN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4162 SKYLAND DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-3558
Mailing Address - Country:US
Mailing Address - Phone:423-723-4442
Mailing Address - Fax:
Practice Address - Street 1:1880 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-5190
Practice Address - Country:US
Practice Address - Phone:423-378-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist