Healthcare Provider Details

I. General information

NPI: 1982654059
Provider Name (Legal Business Name): THOMAS LYNDON GRISSOM DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 SOUTH Y SQUARE
SELMER TN
38375
US

IV. Provider business mailing address

687 COUNTY ROAD 600
CORINTH MS
38834-8379
US

V. Phone/Fax

Practice location:
  • Phone: 731-645-6100
  • Fax: 731-645-4333
Mailing address:
  • Phone: 662-287-5387
  • Fax: 731-645-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6947
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: