Provider Demographics
NPI:1952491888
Name:MICHIE PHARMACY INC
Entity Type:Organization
Organization Name:MICHIE PHARMACY INC
Other - Org Name:MICHIE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHCT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:731-239-2100
Mailing Address - Street 1:5823 HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:MICHIE
Mailing Address - State:TN
Mailing Address - Zip Code:38357-5175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5823 HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:MICHIE
Practice Address - State:TN
Practice Address - Zip Code:38357-5175
Practice Address - Country:US
Practice Address - Phone:731-239-2100
Practice Address - Fax:731-239-2102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TN33113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN195249188Medicaid
2092448OtherPK
3866820051Medicare NSC