MEDICARE: CHARLES WALLACE MARSH III DPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	TN3666	TN

General Provider Information

NPI Number	:	1760480263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES WALLACE MARSH III DPH

Provider Business Mailing Address
First Line	:	605 CLARK BLVD
Second Line	:
City	:	MC MINNVILLE
State	:	TN
Zip	:	37110-1951
Country	:	US
Telephone Number	:	931-473-8944
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 SPARTA ST
Second Line	:
City	:	MC MINNVILLE
State	:	TN
Zip	:	37110-1317
Country	:	US
Telephone Number	:	931-473-4471
Fax Number	:	931-473-2217

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	07/08/2007

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