Provider Demographics
NPI:1760071609
Name:BOOTH, MICHAEL D (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:BOOTH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 BRYNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:TN
Mailing Address - Zip Code:37415-3304
Mailing Address - Country:US
Mailing Address - Phone:423-503-5860
Mailing Address - Fax:
Practice Address - Street 1:1667 OOLTEWAH RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-9830
Practice Address - Country:US
Practice Address - Phone:423-893-6275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN034563183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist