Provider Demographics
NPI:1669412144
Name:JOHN SMITH PROFESSIONAL PHARMACY, INC.
Entity type:Organization
Organization Name:JOHN SMITH PROFESSIONAL PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:S
Authorized Official - Last Name:UPCHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:931-484-1434
Mailing Address - Street 1:100 LANTANA RD
Mailing Address - Street 2:STE. 201
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-1903
Mailing Address - Country:US
Mailing Address - Phone:931-484-1434
Mailing Address - Fax:931-456-2853
Practice Address - Street 1:100 LANTANA RD
Practice Address - Street 2:STE. 201
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-1903
Practice Address - Country:US
Practice Address - Phone:931-484-1434
Practice Address - Fax:931-456-2853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN603336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3513437Medicaid
TN4405797OtherNABP
TN0430940001Medicare ID - Type Unspecified