Provider Demographics
NPI:1407192560
Name:WASSON, MICHAEL D
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:WASSON
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 1:800 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9427
Mailing Address - Country:US
Mailing Address - Phone:901-765-4157
Mailing Address - Fax:
Practice Address - Street 1:800 RIDGE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9427
Practice Address - Country:US
Practice Address - Phone:901-765-4157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9587183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist