Provider Demographics
NPI:1457475683
Name:HARRISON, ROGER (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:HARRISON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37354-0005
Mailing Address - Country:US
Mailing Address - Phone:423-334-5223
Mailing Address - Fax:423-334-9732
Practice Address - Street 1:17619 HWY 58 N
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TN
Practice Address - Zip Code:37322
Practice Address - Country:US
Practice Address - Phone:423-334-5223
Practice Address - Fax:423-334-9732
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist