Provider Demographics
NPI:1457423964
Name:WARTBURG PHARMACY INC
Entity Type:Organization
Organization Name:WARTBURG PHARMACY INC
Other - Org Name:WARTBURG PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-346-2700
Mailing Address - Street 1:PO BOX 1036
Mailing Address - Street 2:
Mailing Address - City:WARTBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37887-1036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1006 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARTBURG
Practice Address - State:TN
Practice Address - Zip Code:37887-4150
Practice Address - Country:US
Practice Address - Phone:423-346-2700
Practice Address - Fax:423-346-2756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN31423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452232Medicaid
2092156OtherPK
1293640001Medicare NSC