Provider Demographics
NPI:1760603005
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:UPPER CUMBERLAND REGIONAL CLINIC DISTRIBUTOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:G
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:931-646-7551
Mailing Address - Street 1:1100 ENGLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0924
Mailing Address - Country:US
Mailing Address - Phone:931-646-7551
Mailing Address - Fax:931-646-7596
Practice Address - Street 1:1100 ENGLAND DRIVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0924
Practice Address - Country:US
Practice Address - Phone:931-646-7551
Practice Address - Fax:931-646-7596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN49088393336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA99051Medicare UPIN
TN3376524Medicare PIN
TN3165714Medicare PIN