Provider Demographics
NPI:1730305673
Name:KINGWOOD PHARMACY
Entity Type:Organization
Organization Name:KINGWOOD PHARMACY
Other - Org Name:KINGWOOD MEDICAL EQUIP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL EQUIPMENT ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-629-1434
Mailing Address - Street 1:3824 RINGGOLD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37412
Mailing Address - Country:US
Mailing Address - Phone:423-624-1434
Mailing Address - Fax:423-629-9646
Practice Address - Street 1:3824 RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37412
Practice Address - Country:US
Practice Address - Phone:423-624-1434
Practice Address - Fax:423-629-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
00025145OtherBLUE CROSS
TN3513189Medicaid
TN3513189Medicaid