Provider Demographics
NPI:1710240932
Name:MORRIS, MICHAEL CLARK
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CLARK
Last Name:MORRIS
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 1:132 WILL HICKERSON RD
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-6779
Mailing Address - Country:US
Mailing Address - Phone:931-455-7065
Mailing Address - Fax:
Practice Address - Street 1:132 WILL HICKERSON RD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-6779
Practice Address - Country:US
Practice Address - Phone:931-455-7065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28988183500000X
KY9999183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9999OtherPHARMACY LICENSE
TN28988OtherPHARMACY LICENSE