Provider Demographics
NPI:1205280807
Name:SPARTA APOTHECARY INC
Entity type:Organization
Organization Name:SPARTA APOTHECARY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TATUM-CRANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:931-836-3187
Mailing Address - Street 1:285 W TURN TABLE RD STE B
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-1366
Mailing Address - Country:US
Mailing Address - Phone:931-836-3187
Mailing Address - Fax:931-836-3398
Practice Address - Street 1:285 W TURN TABLE RD STE B
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-1366
Practice Address - Country:US
Practice Address - Phone:931-836-3187
Practice Address - Fax:931-836-3398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN29293336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9449894Medicaid
2159595OtherPK
1135970001Medicare NSC