Healthcare Provider Details

I. General information

NPI: 1477043768
Provider Name (Legal Business Name): JJ BEANS AT MOONEYS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 N ROAN ST
JOHNSON CITY TN
37601-3901
US

IV. Provider business mailing address

1107 N ROAN ST
JOHNSON CITY TN
37601-3901
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-7333
  • Fax:
Mailing address:
  • Phone: 423-926-7333
  • Fax: 423-926-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1663
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number1663
License Number StateTN

VIII. Authorized Official

Name: DR. CHAD B HUNTSMAN
Title or Position: OWNER
Credential: PHARMD
Phone: 423-312-3856