Healthcare Provider Details

I. General information

NPI: 1740549062
Provider Name (Legal Business Name): WILLIE THIGPEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CHICKADEE AVE
MIDDLETON TN
38052-3425
US

IV. Provider business mailing address

110 CHICKADEE AVE
MIDDLETON TN
38052-3425
US

V. Phone/Fax

Practice location:
  • Phone: 731-376-8251
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberC-2394
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: