Healthcare Provider Details

I. General information

NPI: 1669412144
Provider Name (Legal Business Name): JOHN SMITH PROFESSIONAL PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LANTANA RD STE. 201
CROSSVILLE TN
38555-1903
US

IV. Provider business mailing address

100 LANTANA RD STE. 201
CROSSVILLE TN
38555-1903
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 Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number60
License Number StateTN

VIII. Authorized Official

Name: VICKI S UPCHURCH
Title or Position: PHARMACIST/OWNER
Credential: DPH
Phone: 931-484-1434