Provider Demographics
NPI:1760480263
Name:MARSH, CHARLES WALLACE III (DPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WALLACE
Last Name:MARSH
Suffix:III
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 1:605 CLARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MC MINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1951
Mailing Address - Country:US
Mailing Address - Phone:931-473-8944
Mailing Address - Fax:
Practice Address - Street 1:1500 SPARTA ST
Practice Address - Street 2:
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1317
Practice Address - Country:US
Practice Address - Phone:931-473-4471
Practice Address - Fax:931-473-2217
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN3666183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist