Provider Demographics
NPI:1790919892
Name:MAJOR, MARK A (IDMT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:MAJOR
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:A
Other - Last Name:MAJOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:2045 SEQUOYAH AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-3425
Mailing Address - Country:US
Mailing Address - Phone:865-518-1980
Mailing Address - Fax:
Practice Address - Street 1:945 MCCAMMON AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-3958
Practice Address - Country:US
Practice Address - Phone:865-984-1571
Practice Address - Fax:865-977-9546
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1003X
TN39709183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians