Provider Demographics
NPI:1487852430
Name:GARDNER, THOMAS DERRICK (R,PH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DERRICK
Last Name:GARDNER
Suffix:
Gender:M
Credentials:R,PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4018 BREAKWATER DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3528
Mailing Address - Country:US
Mailing Address - Phone:423-842-2173
Mailing Address - Fax:
Practice Address - Street 1:4018 BREAKWATER DR
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3528
Practice Address - Country:US
Practice Address - Phone:423-842-2173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1278OtherSTATE LICENSE