Healthcare Provider Details

I. General information

NPI: 1205933140
Provider Name (Legal Business Name): MAC'S PHARMACY AT BROWN'S CREEK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 E. LAMAR ALEXANDER PARKWAY
MARYVILLE TN
37804
US

IV. Provider business mailing address

1612 E. LAMAR ALEXANDER PARKWAY
MARYVILLE TN
37804
US

V. Phone/Fax

Practice location:
  • Phone: 865-982-7162
  • Fax: 865-977-4263
Mailing address:
  • Phone: 865-982-7162
  • Fax: 865-977-4263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0000000664
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL WILHOLT
Title or Position: PRESIDENT
Credential: PHARM D
Phone: 865-806-6453