Provider Demographics
NPI:1508086489
Name:WAKEFIELD, DARIEL DUANE JR (DPH)
Entity Type:Individual
Prefix:
First Name:DARIEL
Middle Name:DUANE
Last Name:WAKEFIELD
Suffix:JR
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 DONNA AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2821
Mailing Address - Country:US
Mailing Address - Phone:423-543-8202
Mailing Address - Fax:423-543-1050
Practice Address - Street 1:1001 OVER MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2855
Practice Address - Country:US
Practice Address - Phone:423-543-8202
Practice Address - Fax:423-543-1050
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC0000006335183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist