Healthcare Provider Details

I. General information

NPI: 1972893634
Provider Name (Legal Business Name): COMMUNITY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 N JACKSON ST STE 8
TULLAHOMA TN
37388-2275
US

IV. Provider business mailing address

1805 N JACKSON ST STE 8
TULLAHOMA TN
37388-1821
US

V. Phone/Fax

Practice location:
  • Phone: 931-571-8644
  • Fax: 931-571-8706
Mailing address:
  • Phone: 931-571-8644
  • Fax: 931-571-8706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number34222
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number34222
License Number StateTN

VIII. Authorized Official

Name: DR. ANTHONY AFAMEFUNA OKONKWO
Title or Position: MEMBER
Credential: PHARM. D
Phone: 267-809-1401