Provider Demographics
NPI:1497806434
Name:TANNER, DAVID J (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:TANNER
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355-7606
Mailing Address - Country:US
Mailing Address - Phone:731-783-3036
Mailing Address - Fax:731-423-4590
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-6114
Practice Address - Country:US
Practice Address - Phone:731-427-1528
Practice Address - Fax:731-423-4590
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4406977OtherN.C.P.D.P.
TN3534364Medicaid
TN4406977OtherN.C.P.D.P.