Healthcare Provider Details

I. General information

NPI: 1972417137
Provider Name (Legal Business Name): MAYNARDVILLE DRUG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 MAYNARDVILLE HWY
MAYNARDVILLE TN
37807-3262
US

IV. Provider business mailing address

PO BOX 990
NEW TAZEWELL TN
37824-0990
US

V. Phone/Fax

Practice location:
  • Phone: 865-658-5353
  • Fax: 865-658-5353
Mailing address:
  • Phone: 865-658-5353
  • Fax: 865-658-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHELLE SIMMONS HALFORD
Title or Position: PHARMACY MANAGER
Credential: PHARM D
Phone: 865-278-7895