Healthcare Provider Details

I. General information

NPI: 1073979522
Provider Name (Legal Business Name): JEFF CITY PHARMACIST GROUP LLC DBA MD PHARMACY STORE 2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

657 E BROADWAY BLVD
JEFFERSON CITY TN
37760
US

IV. Provider business mailing address

657 E BROADWAY BLVD
JEFFERSON CITY TN
37760
US

V. Phone/Fax

Practice location:
  • Phone: 865-262-9777
  • Fax: 865-262-9778
Mailing address:
  • Phone: 865-262-9777
  • Fax: 865-262-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5720
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA R BLAKE
Title or Position: PIC
Credential: PHARMD
Phone: 865-262-9777