Healthcare Provider Details

I. General information

NPI: 1316455157
Provider Name (Legal Business Name): JON BRETT MEBANE DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W MAIN ST
CAMDEN TN
38320-1621
US

IV. Provider business mailing address

110 SPRUCE ST N
BRUCETON TN
38317-2034
US

V. Phone/Fax

Practice location:
  • Phone: 731-584-4711
  • Fax: 731-584-5906
Mailing address:
  • Phone: 731-415-0258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8398
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: