Provider Demographics
NPI:1700304839
Name:GOOD SHEPHERD PHARMACY LLC
Entity Type:Organization
Organization Name:GOOD SHEPHERD PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MERVAT
Authorized Official - Middle Name:
Authorized Official - Last Name:FAYEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-554-7140
Mailing Address - Street 1:497 CREEK POINT DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-5600
Mailing Address - Country:US
Mailing Address - Phone:615-554-7140
Mailing Address - Fax:629-202-8956
Practice Address - Street 1:2717 B MURFREESBORO PIKE
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013
Practice Address - Country:US
Practice Address - Phone:615-600-5116
Practice Address - Fax:629-202-8956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN60583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031899Medicaid