Provider Demographics
NPI:1629026109
Name:ASHLEY N TANNER I I I
Entity Type:Organization
Organization Name:ASHLEY N TANNER I I I
Other - Org Name:BAKER DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:731-427-1528
Mailing Address - Street 1:200 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-6114
Mailing Address - Country:US
Mailing Address - Phone:731-427-1528
Mailing Address - Fax:731-423-4590
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-6114
Practice Address - Country:US
Practice Address - Phone:731-427-1528
Practice Address - Fax:731-423-4590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000006903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3534364Medicaid
TN4406977OtherNCPDP
TN1173840001Medicare NSC