Provider Demographics
NPI:1710220918
Name:PHARMACY HOME CARE OF EAST TENNESSEE, INC
Entity Type:Organization
Organization Name:PHARMACY HOME CARE OF EAST TENNESSEE, INC
Other - Org Name:PHARMACY HOME CARE OF EAST TENNESSEE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:WOLFENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:423-790-7336
Mailing Address - Street 1:PO BOX 2607
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37320-2607
Mailing Address - Country:US
Mailing Address - Phone:423-790-7336
Mailing Address - Fax:423-790-7338
Practice Address - Street 1:120 23RD ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3845
Practice Address - Country:US
Practice Address - Phone:423-790-1221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ032865Medicaid
TN4445854OtherNABP
TN5186OtherSTATE LICENSE BOARD OF PHARMACY
TNFP3886489OtherDEA