Healthcare Provider Details

I. General information

NPI: 1972554335
Provider Name (Legal Business Name): CHARLES L PORTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 OLD HIGHWAY 51 S
BRIGHTON TN
38011-8025
US

IV. Provider business mailing address

1880 OLD HIGHWAY 51 S
BRIGHTON TN
38011-8025
US

V. Phone/Fax

Practice location:
  • Phone: 901-837-8981
  • Fax: 901-837-8986
Mailing address:
  • Phone: 901-837-8981
  • Fax: 901-837-8986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0000004268
License Number StateTN

VIII. Authorized Official

Name: CHARLES PORTER
Title or Position: OWNER,PIC,AO
Credential: RPH
Phone: 731-635-5036