Provider Demographics
NPI:1639299027
Name:ELEDGE, JERRY P (DPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:P
Last Name:ELEDGE
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:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37024-0092
Mailing Address - Country:US
Mailing Address - Phone:615-213-1203
Mailing Address - Fax:615-213-1530
Practice Address - Street 1:5150 MURFREESBORO RD # A
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-2712
Practice Address - Country:US
Practice Address - Phone:615-213-1203
Practice Address - Fax:615-213-1530
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist