Provider Demographics
NPI:1477627768
Name:WHITWELL PHARMACY INC
Entity Type:Organization
Organization Name:WHITWELL PHARMACY INC
Other - Org Name:WHITWELL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:STANDEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-877-3568
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:WHITWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37397-0250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13810 HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:WHITWELL
Practice Address - State:TN
Practice Address - Zip Code:37397-5365
Practice Address - Country:US
Practice Address - Phone:423-658-6939
Practice Address - Fax:423-658-0834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN000005983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454266Medicaid
2089515OtherPK
1188470001Medicare NSC