Healthcare Provider Details

I. General information

NPI: 1588006555
Provider Name (Legal Business Name): LANCE WILLOUGHBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 07/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 24TH AVE S
NASHVILLE TN
37212-2637
US

IV. Provider business mailing address

2117 VICTORY GALLOP LN
MURFREESBORO TN
37128-8265
US

V. Phone/Fax

Practice location:
  • Phone: 615-327-4751
  • Fax: 615-321-6350
Mailing address:
  • Phone: 615-818-7288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number0000038444
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: