Healthcare Provider Details

I. General information

NPI: 1881740272
Provider Name (Legal Business Name): JIMMY MAX PETTIGREW AND JAMES B PETTIGREW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 09/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 W MAIN ST
ADAMSVILLE TN
38310-2203
US

IV. Provider business mailing address

PO BOX 409
ADAMSVILLE TN
38310-0409
US

V. Phone/Fax

Practice location:
  • Phone: 731-632-3118
  • Fax: 731-632-0567
Mailing address:
  • Phone: 731-632-3118
  • Fax: 731-632-0567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number101
License Number StateTN

VIII. Authorized Official

Name: JIMMY PETTIGREW
Title or Position: OWNER PHARMACIST
Credential:
Phone: 731-632-3118