Provider Demographics
NPI:1821357609
Name:AUSTIN, VANITA
Entity Type:Individual
Prefix:
First Name:VANITA
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1789 NEW HOPE ROAD
Mailing Address - Street 2:
Mailing Address - City:GUYS
Mailing Address - State:TN
Mailing Address - Zip Code:38339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1789 NEW HOPE ROAD
Practice Address - Street 2:
Practice Address - City:GUYS
Practice Address - State:TN
Practice Address - Zip Code:38339
Practice Address - Country:US
Practice Address - Phone:731-645-7398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC4372183500000X
MSR6571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist