Provider Demographics
NPI:1508909961
Name:RODERICK A GALLAHER
Entity Type:Organization
Organization Name:RODERICK A GALLAHER
Other - Org Name:SIGNAL MOUNTAIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLAHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-886-2135
Mailing Address - Street 1:804 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-3065
Mailing Address - Country:US
Mailing Address - Phone:423-886-2135
Mailing Address - Fax:423-886-6035
Practice Address - Street 1:804 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:SIGNAL MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37377-3065
Practice Address - Country:US
Practice Address - Phone:423-886-2135
Practice Address - Fax:423-886-6035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3517460Medicaid
0152610001Medicare ID - Type Unspecified