Provider Demographics
NPI:1568437945
Name:MIKE SWAIM VAN SWAIM CASEY VERNON
Entity Type:Organization
Organization Name:MIKE SWAIM VAN SWAIM CASEY VERNON
Other - Org Name:EASTWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAC
Authorized Official - Middle Name:CASEY
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:731-642-0451
Mailing Address - Street 1:1325 E WOOD ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-4421
Mailing Address - Country:US
Mailing Address - Phone:731-642-0451
Mailing Address - Fax:731-642-4034
Practice Address - Street 1:1325 E WOOD ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4421
Practice Address - Country:US
Practice Address - Phone:731-642-0451
Practice Address - Fax:731-642-4034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN311333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452214Medicaid
TN1299280001Medicare ID - Type Unspecified