Provider Demographics
NPI:1417048760
Name:PROFFITT, LARRY MICHAEL (DPH)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:MICHAEL
Last Name:PROFFITT
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 1:1000 WEST G ST
Mailing Address - Street 2:BURGIE DRUGSTORE LLC
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643
Mailing Address - Country:US
Mailing Address - Phone:423-542-4622
Mailing Address - Fax:423-542-2564
Practice Address - Street 1:1000 WEST G ST
Practice Address - Street 2:BURGIE DRUGSTORE LLC
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643
Practice Address - Country:US
Practice Address - Phone:423-542-4622
Practice Address - Fax:423-542-2564
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist