Provider Demographics
NPI:1669865440
Name:CORUM, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CORUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:868 SELLERS RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-4203
Mailing Address - Country:US
Mailing Address - Phone:865-591-6942
Mailing Address - Fax:
Practice Address - Street 1:1212 STATE ST
Practice Address - Street 2:
Practice Address - City:WHITE PINE
Practice Address - State:TN
Practice Address - Zip Code:37890-3467
Practice Address - Country:US
Practice Address - Phone:865-674-7517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9174183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist