Provider Demographics
NPI:1780784637
Name:REED, MARK A (DPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:REED
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BROYLES ST
Mailing Address - Street 2:STE A
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2542
Mailing Address - Country:US
Mailing Address - Phone:423-282-1178
Mailing Address - Fax:423-282-0462
Practice Address - Street 1:105 BROYLES ST
Practice Address - Street 2:STE A
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2542
Practice Address - Country:US
Practice Address - Phone:423-282-1178
Practice Address - Fax:423-282-0462
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0167780001Medicare NSC