=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114703865
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY WADE PHILLIPS DPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2023
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2525 DESALES AVE STE 4900
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37404-1102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-495-8981
-----------------------------------------------------
Fax | 423-495-6136
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1836 COLONIAL WAY CIR
-----------------------------------------------------
City | HIXSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37343-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-997-2950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 33413
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------