Provider Demographics
NPI:1992215065
Name:METRA, CARLVIN JON M (PHARMD)
Entity Type:Individual
Prefix:
First Name:CARLVIN JON
Middle Name:M
Last Name:METRA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1388 HARBOR PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-9031
Mailing Address - Country:US
Mailing Address - Phone:619-788-3407
Mailing Address - Fax:
Practice Address - Street 1:1810 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3941
Practice Address - Country:US
Practice Address - Phone:901-272-6191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist