Provider Demographics
NPI:1851302434
Name:PHARMACY HOME DELIVERY LLC
Entity Type:Organization
Organization Name:PHARMACY HOME DELIVERY LLC
Other - Org Name:PHD LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:H DON
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-862-1456
Mailing Address - Street 1:PO BOX 3296
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37320-3296
Mailing Address - Country:US
Mailing Address - Phone:800-862-1456
Mailing Address - Fax:888-805-2406
Practice Address - Street 1:110 KEITH ST SW
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-5868
Practice Address - Country:US
Practice Address - Phone:423-614-6650
Practice Address - Fax:423-614-6652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TN42193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2094872OtherPK
TN4438760Medicaid
2094872OtherPK