Provider Demographics
NPI:1467401893
Name:SMITH, TONJA MEDIVAL (DPH)
Entity Type:Individual
Prefix:MS
First Name:TONJA
Middle Name:MEDIVAL
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 US HIGHWAY 64 G
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38075-7476
Mailing Address - Country:US
Mailing Address - Phone:731-859-5016
Mailing Address - Fax:731-859-5017
Practice Address - Street 1:2861 BROAD AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-2903
Practice Address - Country:US
Practice Address - Phone:901-260-8500
Practice Address - Fax:901-325-6469
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist