Healthcare Provider Details

I. General information

NPI: 1598754541
Provider Name (Legal Business Name): LARRY ARTHUR WILEY DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 MAIN STREET BOX 157
ALTAMONT TN
37301
US

IV. Provider business mailing address

1595 MAIN STREET P. O. BOX 157
ALTAMONT TN
37301
US

V. Phone/Fax

Practice location:
  • Phone: 931-779-2217
  • Fax: 931-692-3889
Mailing address:
  • Phone: 931-779-2217
  • Fax: 931-692-3889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5630
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: