Healthcare Provider Details

I. General information

NPI: 1689858821
Provider Name (Legal Business Name): HOMETOWN PHARMACY OF MEDINA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 HWY 45 BYPASS
MEDINA TN
38355
US

IV. Provider business mailing address

PO BOX 310
MEDINA TN
38355
US

V. Phone/Fax

Practice location:
  • Phone: 731-783-0777
  • Fax: 731-783-3005
Mailing address:
  • Phone: 731-783-0777
  • Fax: 731-783-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: J MARK BOWERS
Title or Position: PRESIDENT
Credential:
Phone: 731-783-0777