Healthcare Provider Details

I. General information

NPI: 1992788913
Provider Name (Legal Business Name): TOMMY STEVEN WILMORE DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 MAIN ST N
CARTHAGE TN
37030
US

IV. Provider business mailing address

5 HALIBURTON LN
RIDDLETON TN
37151-2221
US

V. Phone/Fax

Practice location:
  • Phone: 615-735-2060
  • Fax:
Mailing address:
  • Phone: 615-735-0810
  • Fax: 615-735-1077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3963
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: