Healthcare Provider Details

I. General information

NPI: 1457475683
Provider Name (Legal Business Name): ROGER HARRISON PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17619 HWY 58 N
DECATUR TN
37322
US

IV. Provider business mailing address

PO BOX 5
MADISONVILLE TN
37354-0005
US

V. Phone/Fax

Practice location:
  • Phone: 423-334-5223
  • Fax: 423-334-9732
Mailing address:
  • Phone: 423-334-5223
  • Fax: 423-334-9732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5021
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: