Healthcare Provider Details

I. General information

NPI: 1639856081
Provider Name (Legal Business Name): MALIYAH VILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 NASHVILLE HWY
COLUMBIA TN
38401-2430
US

IV. Provider business mailing address

6746 POLK LN
COLUMBIA TN
38401-7908
US

V. Phone/Fax

Practice location:
  • Phone: 931-380-3065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number0000079447
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: