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General NPI Number Information
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NPI Number | 1184153264
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Entity Type | Individual
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Provider Name | TARA MISTELL DOUGLAS
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Gender | Female
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Dates
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Enumeration Date | 06/12/2017
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Last Update Date | 06/12/2017
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Provider Practice Location Address
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Address Line | 279 UNDERPASS DR
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City | ONEIDA
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State | TN
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Zip | 37841-5885
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Country | US
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Telephone | 423-569-7800
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Fax |
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Provider Business Mailing Address
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Address Line | 749 BART GRANT HOLLOW RD
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City | WINFIELD
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State | TN
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Zip | 37892-3664
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183700000X
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Taxonomy Name | Pharmacy Technician
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License Number | 19006
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License Number State | TN
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