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General NPI Number Information
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NPI Number | 1174834758
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Entity Type | Organization
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Legal Business Name | FORMULAB LLC
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Dates
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Enumeration Date | 06/29/2010
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Last Update Date | 05/16/2011
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Provider Practice Location Address
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Address Line | 5821 WALDEN DR
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City | KNOXVILLE
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State | TN
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Zip | 37919-6334
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Country | US
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Telephone | 865-588-0689
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Fax | 865-588-0680
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Provider Business Mailing Address
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Address Line | 5821 WALDEN DR
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City | KNOXVILLE
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State | TN
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Zip | 37919-6334
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Country | US
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Telephone | 865-588-0689
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Fax | 865-588-0680
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Authorized Official
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Title or Position | MEMBER
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Name | SCOTTY WYATT
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Credential |
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Telephone | 865-588-0689
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 128
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License Number State | TN
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