Provider Demographics
NPI:1255535183
Name:BANTOM, RHONDA GADDY
Entity type:Individual
Prefix:MRS
First Name:RHONDA
Middle Name:GADDY
Last Name:BANTOM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:RONDA
Other - Middle Name:GADDY
Other - Last Name:BANTOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8862 RIVER PINE DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-7100
Mailing Address - Country:US
Mailing Address - Phone:901-251-0152
Mailing Address - Fax:
Practice Address - Street 1:8862 RIVER PINE DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-7100
Practice Address - Country:US
Practice Address - Phone:901-251-0152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist