Provider Demographics
NPI:1518317411
Name:PINK GLITTER THRIFT BOUTIQUE
Entity Type:Organization
Organization Name:PINK GLITTER THRIFT BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-358-7465
Mailing Address - Street 1:3854 DICKERSON PIKE
Mailing Address - Street 2:SUITE C
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37207-1318
Mailing Address - Country:US
Mailing Address - Phone:615-358-7465
Mailing Address - Fax:
Practice Address - Street 1:3854 DICKERSON PIKE
Practice Address - Street 2:SUITE C
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37207-1318
Practice Address - Country:US
Practice Address - Phone:615-358-7465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN94719332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies