Provider Demographics
NPI:1598754541
Name:WILEY, LARRY ARTHUR (DPH)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ARTHUR
Last Name:WILEY
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 1:1595 MAIN STREET
Mailing Address - Street 2:P. O. BOX 157
Mailing Address - City:ALTAMONT
Mailing Address - State:TN
Mailing Address - Zip Code:37301
Mailing Address - Country:US
Mailing Address - Phone:931-779-2217
Mailing Address - Fax:931-692-3889
Practice Address - Street 1:1595 MAIN STREET
Practice Address - Street 2:BOX 157
Practice Address - City:ALTAMONT
Practice Address - State:TN
Practice Address - Zip Code:37301
Practice Address - Country:US
Practice Address - Phone:931-779-2217
Practice Address - Fax:931-692-3889
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5630183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN354-7472Medicaid
TN5038920001Medicare ID - Type Unspecified