Provider Demographics
NPI:1497790786
Name:MIDDLE TENNESSEE PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:MIDDLE TENNESSEE PHARMACY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:931-684-9987
Mailing Address - Street 1:336 S CANNON BLVD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-3914
Mailing Address - Country:US
Mailing Address - Phone:931-684-9987
Mailing Address - Fax:931-684-9995
Practice Address - Street 1:336 S CANNON BLVD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3914
Practice Address - Country:US
Practice Address - Phone:931-684-9987
Practice Address - Fax:931-684-9995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000004147332BP3500X, 3336C0004X, 3336H0001X, 3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4438140Medicaid
TN4135181OtherBCBS TN DME
TN4138194OtherBCBS TN HIT
TN1455133OtherTENNCARE
TN1455133OtherTENNCARE
TN4138194OtherBCBS TN HIT
TN1455133OtherTENNCARE