Provider Demographics
NPI:1902822521
Name:TAMER, RISSA PRYSE (DPH)
Entity Type:Individual
Prefix:MRS
First Name:RISSA
Middle Name:PRYSE
Last Name:TAMER
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 866
Mailing Address - Street 2:
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-0866
Mailing Address - Country:US
Mailing Address - Phone:423-563-7455
Mailing Address - Fax:423-563-7448
Practice Address - Street 1:3088 APPALACHIAN HWY
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-2526
Practice Address - Country:US
Practice Address - Phone:423-563-7455
Practice Address - Fax:423-563-7448
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454115Medicaid
TN3536986Medicaid
TN1454115Medicaid
TN0236210001Medicare NSC