Provider Demographics
NPI:1457465346
Name:CENTRAL DRUG CO PEERLESS CROSSING
Entity Type:Organization
Organization Name:CENTRAL DRUG CO PEERLESS CROSSING
Other - Org Name:CENTRAL DRUG PEERLESS CROSSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:423-476-4597
Mailing Address - Street 1:1075 PEERLESS XING NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3764
Mailing Address - Country:US
Mailing Address - Phone:423-339-3363
Mailing Address - Fax:423-339-9692
Practice Address - Street 1:1075 PEERLESS XING NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3764
Practice Address - Country:US
Practice Address - Phone:423-339-3363
Practice Address - Fax:423-339-9692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1455229Medicaid
2095023OtherPK