Healthcare Provider Details

I. General information

NPI: 1033406111
Provider Name (Legal Business Name): MEDIPHARM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 S BELLEVUE BLVD SUITE # 3
MEMPHIS TN
38104-7517
US

IV. Provider business mailing address

295 S BELLEVUE BLVD SUITE # 3
MEMPHIS TN
38104-7517
US

V. Phone/Fax

Practice location:
  • Phone: 901-746-9631
  • Fax: 901-791-9292
Mailing address:
  • Phone: 901-746-9631
  • Fax: 901-791-9292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN 16134
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number44D2021574
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD7664
License Number StateTN

VIII. Authorized Official

Name: NYANDAY R. OTI
Title or Position: ADMINISTRATOR/CEO
Credential:
Phone: 901-746-9631