Provider Demographics
NPI:1659869246
Name:BROCK, MICAH
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 CHAPMAN HWY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-6614
Mailing Address - Country:US
Mailing Address - Phone:865-577-4883
Mailing Address - Fax:
Practice Address - Street 1:7420 CHAPMAN HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-6614
Practice Address - Country:US
Practice Address - Phone:865-577-4883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-29
Last Update Date:2018-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000039712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist