Healthcare Provider Details

I. General information

NPI: 1831272129
Provider Name (Legal Business Name): MINNIS DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 TENNOVA MEDICAL WAY
KNOXVILLE TN
37909-3120
US

IV. Provider business mailing address

PO BOX 369
MORRISTOWN TN
37815-0369
US

V. Phone/Fax

Practice location:
  • Phone: 865-895-6072
  • Fax:
Mailing address:
  • Phone: 423-586-4562
  • Fax: 423-587-5537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number0000001975
License Number StateTN

VIII. Authorized Official

Name: MR. ROBERT KENNETH CANTWELL
Title or Position: OWNER CHIEF PHARMICIST
Credential: DPH PHARMACY
Phone: 423-586-4562