Provider Demographics
NPI:1770645475
Name:TALLENT DRUG STORE
Entity Type:Organization
Organization Name:TALLENT DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:E.
Authorized Official - Middle Name:R
Authorized Official - Last Name:DYKES
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:423-442-2400
Mailing Address - Street 1:126 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37354-1474
Mailing Address - Country:US
Mailing Address - Phone:423-442-2400
Mailing Address - Fax:423-442-4006
Practice Address - Street 1:126 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354-1474
Practice Address - Country:US
Practice Address - Phone:423-442-2400
Practice Address - Fax:423-442-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN653183500000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452287Medicaid
TN1186570001Medicare NSC
TN4408539Medicare UPIN