Healthcare Provider Details

I. General information

NPI: 1649649849
Provider Name (Legal Business Name): ROCKY TOP PHARMACY OF LOUDON INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 GROVE ST
LOUDON TN
37774-1481
US

IV. Provider business mailing address

106 ADMINISTRATION RD
OAK RIDGE TN
37830-6954
US

V. Phone/Fax

Practice location:
  • Phone: 865-657-3500
  • Fax: 865-657-3502
Mailing address:
  • Phone: 865-566-1909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5658
License Number StateTN

VIII. Authorized Official

Name: CHARLIE DAVID COSCIA
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential: PHARMD
Phone: 865-657-3500