Provider Demographics
NPI:1376526517
Name:DYER STATION PHARMACY, LLC
Entity Type:Organization
Organization Name:DYER STATION PHARMACY, LLC
Other - Org Name:DUNCAN'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:731-692-3578
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:TN
Mailing Address - Zip Code:38330-0265
Mailing Address - Country:US
Mailing Address - Phone:731-692-3578
Mailing Address - Fax:731-692-4219
Practice Address - Street 1:137 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:TN
Practice Address - Zip Code:38330-1815
Practice Address - Country:US
Practice Address - Phone:731-692-3578
Practice Address - Fax:731-692-4219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
TN2878333600000X, 3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454681Medicaid
5314840001Medicare NSC