Healthcare Provider Details

I. General information

NPI: 1942124334
Provider Name (Legal Business Name): RXREVIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MAIN STREET
SAVANNAH TN
38372-2412
US

IV. Provider business mailing address

112 MAIN STREET
SAVANNAH TN
38372-2412
US

V. Phone/Fax

Practice location:
  • Phone: 731-327-6285
  • Fax: 731-925-6247
Mailing address:
  • Phone: 731-327-6285
  • Fax: 731-925-6247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELA JEAN ETHERIDGE
Title or Position: OWNER
Credential: PHARM D
Phone: 731-925-0838