Provider Demographics
NPI:1629196472
Name:MEDICINE CHEST APOTHECARY
Entity Type:Organization
Organization Name:MEDICINE CHEST APOTHECARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:SELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:931-528-8479
Mailing Address - Street 1:330 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2440
Mailing Address - Country:US
Mailing Address - Phone:931-528-8479
Mailing Address - Fax:
Practice Address - Street 1:330 N OAK AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2440
Practice Address - Country:US
Practice Address - Phone:931-528-8479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3544998Medicaid
TN4418100OtherNCPDP
TNAM9446344OtherDEA
TN3544998Medicaid