Provider Demographics
NPI:1881740272
Name:JIMMY MAX PETTIGREW AND JAMES B PETTIGREW
Entity type:Organization
Organization Name:JIMMY MAX PETTIGREW AND JAMES B PETTIGREW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIGREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-632-3118
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:
Mailing Address - City:ADAMSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38310-0409
Mailing Address - Country:US
Mailing Address - Phone:731-632-3118
Mailing Address - Fax:731-632-0567
Practice Address - Street 1:139 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ADAMSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38310-2203
Practice Address - Country:US
Practice Address - Phone:731-632-3118
Practice Address - Fax:731-632-0567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095053OtherPK
2095053OtherPK