Healthcare Provider Details

I. General information

NPI: 1407007222
Provider Name (Legal Business Name): MAIN STREET FAMILY PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E MAIN ST
NEWBERN TN
38059-1527
US

IV. Provider business mailing address

126 E MAIN ST
NEWBERN TN
38059-1527
US

V. Phone/Fax

Practice location:
  • Phone: 731-627-2221
  • Fax: 731-627-6152
Mailing address:
  • Phone: 731-627-2221
  • Fax: 731-627-6152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0000000895
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0000000895
License Number StateTN

VIII. Authorized Official

Name: CHRISTY NEWBAKER
Title or Position: OWNER
Credential:
Phone: 731-627-2221