Provider Demographics
NPI:1184785362
Name:JEFFCO DRUGCENTER IN DANDRIDGE, INC.
Entity type:Organization
Organization Name:JEFFCO DRUGCENTER IN DANDRIDGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:865-397-2868
Mailing Address - Street 1:PO BOX 1191
Mailing Address - Street 2:
Mailing Address - City:DANDRIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37725-1191
Mailing Address - Country:US
Mailing Address - Phone:865-397-2868
Mailing Address - Fax:865-397-5100
Practice Address - Street 1:127 W. MEETING ST
Practice Address - Street 2:
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725
Practice Address - Country:US
Practice Address - Phone:865-397-2868
Practice Address - Fax:865-397-5100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8733183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4091260001Medicare NSC