Healthcare Provider Details

I. General information

NPI: 1528635455
Provider Name (Legal Business Name): EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 CLINCH AVENUE OUTPATIENT PHARMACY
KNOXVILLE TN
37916-2301
US

IV. Provider business mailing address

2018 CLINCH AVENUE OUTPATIENT PHARMACY
KNOXVILLE TN
37916-2301
US

V. Phone/Fax

Practice location:
  • Phone: 865-541-8980
  • Fax: 865-541-8429
Mailing address:
  • Phone: 865-541-8980
  • Fax: 865-541-8429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. STEVEN R GODBOLD
Title or Position: VICE PRESIDENT - OPERATIONS
Credential:
Phone: 865-541-8492