Provider Demographics
NPI:1790770519
Name:GOOD OLD DRUGSTORE INC
Entity Type:Organization
Organization Name:GOOD OLD DRUGSTORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-497-9999
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:TN
Mailing Address - Zip Code:37888-0098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8295 HIGHWAY 131
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:TN
Practice Address - Zip Code:37888
Practice Address - Country:US
Practice Address - Phone:865-497-9999
Practice Address - Fax:865-497-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN41933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4438443OtherOTHER ID NUMBER