Provider Demographics
NPI:1558429779
Name:MOTHERAL, JOHN E (DPH)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:MOTHERAL
Suffix:
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 1:2340 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-2249
Mailing Address - Country:US
Mailing Address - Phone:731-352-3242
Mailing Address - Fax:731-352-5860
Practice Address - Street 1:2340 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-2249
Practice Address - Country:US
Practice Address - Phone:731-352-3242
Practice Address - Fax:731-352-5860
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002625183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist