Provider Demographics
NPI:1982654059
Name:GRISSOM, THOMAS LYNDON (DPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LYNDON
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 COUNTY ROAD 600
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-8379
Mailing Address - Country:US
Mailing Address - Phone:662-287-5387
Mailing Address - Fax:731-645-4333
Practice Address - Street 1:103 SOUTH Y SQUARE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375
Practice Address - Country:US
Practice Address - Phone:731-645-6100
Practice Address - Fax:731-645-4333
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist