Provider Demographics
NPI:1912452590
Name:DIXIE PHARMACY-3 LLC
Entity Type:Organization
Organization Name:DIXIE PHARMACY-3 LLC
Other - Org Name:DIXIE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAJIUDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:615-686-6420
Mailing Address - Street 1:311 LANDRUM PL
Mailing Address - Street 2:SUITE 600-A
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-6319
Mailing Address - Country:US
Mailing Address - Phone:931-241-5688
Mailing Address - Fax:931-241-5686
Practice Address - Street 1:311 LANDRUM PL
Practice Address - Street 2:SUITE 600-A
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6319
Practice Address - Country:US
Practice Address - Phone:931-241-5688
Practice Address - Fax:931-241-5686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TN000058663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164376OtherPK