=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245383082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA BETH PORTRUM PHARM D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1035 S CUMBERLAND ST
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37813-5236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-586-6271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1123 CASTILE AVE
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37814-3465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-586-4562
-----------------------------------------------------
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 | 8265
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------