Provider Demographics
NPI:1376583096
Name:PORTER, CHARLES L
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:PORTER
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 1:1880 OLD HWY 51
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:TN
Mailing Address - Zip Code:38011
Mailing Address - Country:US
Mailing Address - Phone:901-837-8981
Mailing Address - Fax:901-837-8986
Practice Address - Street 1:1880 OLD HWY 51
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:TN
Practice Address - Zip Code:38011
Practice Address - Country:US
Practice Address - Phone:901-837-8981
Practice Address - Fax:901-837-8986
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4268183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist