Provider Demographics
NPI:1417177528
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:SOUTHEAST TN REG PUBLIC HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTANT 3
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-634-5832
Mailing Address - Street 1:540 MCCALLIE AVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-2089
Mailing Address - Country:US
Mailing Address - Phone:423-634-3124
Mailing Address - Fax:
Practice Address - Street 1:540 MCCALLIE AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-2089
Practice Address - Country:US
Practice Address - Phone:423-634-3124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare