Provider Demographics
NPI:1578099016
Name:WINDHAM DRUG JELLICO, INC
Entity Type:Organization
Organization Name:WINDHAM DRUG JELLICO, INC
Other - Org Name:WINDHAM DRUG JELLICO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:423-784-3630
Mailing Address - Street 1:1184 5TH ST
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2629
Mailing Address - Country:US
Mailing Address - Phone:423-784-3630
Mailing Address - Fax:
Practice Address - Street 1:1184 5TH ST
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-2629
Practice Address - Country:US
Practice Address - Phone:423-784-3630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TN3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies