Provider Demographics
NPI:1689279945
Name:CENTRAL DRUG STORE PLLC
Entity Type:Organization
Organization Name:CENTRAL DRUG STORE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:423-638-4711
Mailing Address - Street 1:239 W SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37743-4925
Mailing Address - Country:US
Mailing Address - Phone:423-638-4711
Mailing Address - Fax:423-638-3311
Practice Address - Street 1:239 W SUMMER ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-4925
Practice Address - Country:US
Practice Address - Phone:423-638-4711
Practice Address - Fax:423-638-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454403Medicaid