Provider Demographics
NPI:1598034142
Name:FONTENOT, IRA DEAN (PD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:DEAN
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 W TREE DR
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-1329
Mailing Address - Country:US
Mailing Address - Phone:901-850-5978
Mailing Address - Fax:
Practice Address - Street 1:998 W TREE DR
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-1329
Practice Address - Country:US
Practice Address - Phone:901-850-5978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist