Provider Demographics
NPI:1477697589
Name:FOUR WAY PRESCRIPTION SHOP
Entity type:Organization
Organization Name:FOUR WAY PRESCRIPTION SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:865-933-2451
Mailing Address - Street 1:8707A ASHEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37924-4502
Mailing Address - Country:US
Mailing Address - Phone:865-933-2451
Mailing Address - Fax:865-932-1838
Practice Address - Street 1:8707A ASHEVILLE HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37924-4502
Practice Address - Country:US
Practice Address - Phone:865-933-2451
Practice Address - Fax:865-932-1838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3562149Medicaid
TN1172760001Medicare NSC
TNC08428284Medicare ID - Type UnspecifiedMEDICARE SUBMITTER #