Provider Demographics
NPI:1205909686
Name:NEWPORT DRUG STORE, INC.
Entity type:Organization
Organization Name:NEWPORT DRUG STORE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:423-623-6166
Mailing Address - Street 1:646 COSBY HWY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3418
Mailing Address - Country:US
Mailing Address - Phone:423-623-6166
Mailing Address - Fax:423-623-6167
Practice Address - Street 1:646 COSBY HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3418
Practice Address - Country:US
Practice Address - Phone:423-623-6166
Practice Address - Fax:423-623-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5284183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454531Medicaid
TN1454531Medicaid