Provider Demographics
NPI:1710161724
Name:COWAN, WESLEY TAYLOR (DPH)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:TAYLOR
Last Name:COWAN
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 1:1721 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WHITE PINE
Mailing Address - State:TN
Mailing Address - Zip Code:37890-0670
Mailing Address - Country:US
Mailing Address - Phone:865-674-6700
Mailing Address - Fax:865-674-6704
Practice Address - Street 1:1721 MAIN ST.
Practice Address - Street 2:
Practice Address - City:WHITE PINE
Practice Address - State:TN
Practice Address - Zip Code:37890-0670
Practice Address - Country:US
Practice Address - Phone:865-674-6700
Practice Address - Fax:865-674-6704
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2342183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1168140001Medicare PIN