Healthcare Provider Details

I. General information

NPI: 1770613424
Provider Name (Legal Business Name): VICKI S UPCHURCH D.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LANTANA RD STE. 201
CROSSVILLE TN
38555-1915
US

IV. Provider business mailing address

100 LANTANA RD STE. 201
CROSSVILLE TN
38555-1915
US

V. Phone/Fax

Practice location:
  • Phone: 931-484-1434
  • Fax: 931-456-2853
Mailing address:
  • Phone: 931-484-1434
  • Fax: 931-456-2853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4858
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: