Provider Demographics
NPI:1205110491
Name:IRWIN, RAY HOWE JR
Entity type:Individual
Prefix:MR
First Name:RAY
Middle Name:HOWE
Last Name:IRWIN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 HILLTOP LN
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-3036
Mailing Address - Country:US
Mailing Address - Phone:423-562-3360
Mailing Address - Fax:
Practice Address - Street 1:2109 JACKSBORO PIKE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-3003
Practice Address - Country:US
Practice Address - Phone:423-566-0774
Practice Address - Fax:423-566-0864
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN08332183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist