Healthcare Provider Details

I. General information

NPI: 1780980631
Provider Name (Legal Business Name): MEDIPHARM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 S BELLEVUE BLVD STE 1A
MEMPHIS TN
38104-7517
US

IV. Provider business mailing address

295 S BELLEVUE BLVD SUITE 1
MEMPHIS TN
38104-7517
US

V. Phone/Fax

Practice location:
  • Phone: 901-373-9955
  • Fax: 901-382-9966
Mailing address:
  • Phone: 901-373-9955
  • Fax: 901-382-9966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number4821
License Number StateTN

VIII. Authorized Official

Name: NYANDAY OTI
Title or Position: ADMINISTRATOR
Credential:
Phone: 901-373-9955