Provider Demographics
NPI:1568247724
Name:PHILLIPS, WYNTON
Entity Type:Individual
Prefix:
First Name:WYNTON
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 TINNEL RD
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-6164
Mailing Address - Country:US
Mailing Address - Phone:865-202-7380
Mailing Address - Fax:
Practice Address - Street 1:2799 HIGHWAY 72 N
Practice Address - Street 2:
Practice Address - City:LOUDON
Practice Address - State:TN
Practice Address - Zip Code:37774-5725
Practice Address - Country:US
Practice Address - Phone:865-458-5312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist