Provider Demographics
NPI:1881799641
Name:ST BETHLEHEM DRUGS INC NEW CORP
Entity type:Organization
Organization Name:ST BETHLEHEM DRUGS INC NEW CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-289-8991
Mailing Address - Street 1:800 WEATHERLY DR
Mailing Address - Street 2:SUITE 101A
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8957
Mailing Address - Country:US
Mailing Address - Phone:931-647-6561
Mailing Address - Fax:931-906-1254
Practice Address - Street 1:800 WEATHERLY DR
Practice Address - Street 2:SUITE 101A
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8957
Practice Address - Country:US
Practice Address - Phone:931-647-6561
Practice Address - Fax:931-906-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000022933336C0003X, 3336C0003X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160660OtherPK
TN3562433Medicaid
TN3562433Medicaid