Healthcare Provider Details

I. General information

NPI: 1730294778
Provider Name (Legal Business Name): GREG EDGIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 HIGHWAY 114 S
SCOTTS HILL TN
38374-5023
US

IV. Provider business mailing address

PO BOX 247 640 HWY 114 SOUTH
SCOTTS HILL TN
38374-0247
US

V. Phone/Fax

Practice location:
  • Phone: 731-549-3927
  • Fax: 731-549-2323
Mailing address:
  • Phone: 731-549-3927
  • Fax: 731-549-2323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2086
License Number StateTN

VIII. Authorized Official

Name: GREG EDGIN
Title or Position: OWNER PHARMACIST
Credential: DPH
Phone: 731-549-3927