Provider Demographics
NPI:1700550753
Name:BANCROFT, ALEXA NOELLE DODSON
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:NOELLE DODSON
Last Name:BANCROFT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 TOMAHAWK CIR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3462
Mailing Address - Country:US
Mailing Address - Phone:423-284-9616
Mailing Address - Fax:
Practice Address - Street 1:1114 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4150
Practice Address - Country:US
Practice Address - Phone:423-745-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45131183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist