Provider Demographics
NPI:1477623817
Name:PETTY, JAMES ALBERT
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALBERT
Last Name:PETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 WATERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-5707
Mailing Address - Country:US
Mailing Address - Phone:931-456-4440
Mailing Address - Fax:931-456-2710
Practice Address - Street 1:97 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4500
Practice Address - Country:US
Practice Address - Phone:931-484-5117
Practice Address - Fax:931-456-2710
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC-5721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist