Provider Demographics
NPI:1942588645
Name:MID-TOWN PHARMACY LLC
Entity Type:Organization
Organization Name:MID-TOWN PHARMACY LLC
Other - Org Name:MID-TOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:731-645-7008
Mailing Address - Street 1:270 E COURT AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-2304
Mailing Address - Country:US
Mailing Address - Phone:731-645-7008
Mailing Address - Fax:731-982-7006
Practice Address - Street 1:270 E COURT AVE STE C
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-2304
Practice Address - Country:US
Practice Address - Phone:731-645-7008
Practice Address - Fax:731-982-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TN000049023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131475OtherPK