Provider Demographics
NPI:1982056529
Name:PHARMBLUE TENNESSEE LLC
Entity Type:Organization
Organization Name:PHARMBLUE TENNESSEE LLC
Other - Org Name:PHARMBLUE TENNESSEE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, CEO, AO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-779-4720
Mailing Address - Street 1:40 PENNWOOD PL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WARRENDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15086-6526
Mailing Address - Country:US
Mailing Address - Phone:724-779-4720
Mailing Address - Fax:724-779-4721
Practice Address - Street 1:1113 MURFREESBORO RD STE 319-B
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-1306
Practice Address - Country:US
Practice Address - Phone:615-656-5417
Practice Address - Fax:855-331-4245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336S0011X
TN00000058653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162030OtherPK
TN1982056529Medicaid