Provider Demographics
NPI:1770878969
Name:NORTHEAST TENNESSEE DISPENSARY OF HOPE PHARMACY
Entity type:Organization
Organization Name:NORTHEAST TENNESSEE DISPENSARY OF HOPE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY SITE MANAGER/PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM-D
Authorized Official - Phone:423-431-1570
Mailing Address - Street 1:401A ELM ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4601
Mailing Address - Country:US
Mailing Address - Phone:423-431-1570
Mailing Address - Fax:
Practice Address - Street 1:401A ELM ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4601
Practice Address - Country:US
Practice Address - Phone:423-431-1570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN STATE HEALTH ALLIANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN046403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy