Provider Demographics
NPI:1265514046
Name:VANTREESE DISCOUNT PHARMACY INC
Entity type:Organization
Organization Name:VANTREESE DISCOUNT PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANGER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMASTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:731-423-0316
Mailing Address - Street 1:1463 S HIGHLAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-7543
Mailing Address - Country:US
Mailing Address - Phone:731-423-0316
Mailing Address - Fax:731-424-5124
Practice Address - Street 1:1463 S HIGHLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7543
Practice Address - Country:US
Practice Address - Phone:731-423-0316
Practice Address - Fax:731-424-5124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X
TN2903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9448434Medicaid
2088846OtherPK
TN1455247Medicaid