Provider Demographics
NPI:1891837654
Name:JOHN E MOTHERAL
Entity Type:Organization
Organization Name:JOHN E MOTHERAL
Other - Org Name:MOTHERAL SUPER DRUG
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MOTHERAL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:731-352-3242
Mailing Address - Street 1:2340 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-2249
Mailing Address - Country:US
Mailing Address - Phone:731-352-3242
Mailing Address - Fax:731-352-5860
Practice Address - Street 1:2340 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-2249
Practice Address - Country:US
Practice Address - Phone:731-352-3242
Practice Address - Fax:731-352-5860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452452Medicaid
TN1174610001Medicare NSC