=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255818860
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHESNEY GANNAWAY PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2018
-----------------------------------------------------
Last Update Date | 07/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4470 N ROAN ST
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37615-4922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-282-0055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 HERITAGE CT
-----------------------------------------------------
City | JONESBOROUGH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37659-5878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-276-5220
-----------------------------------------------------
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 | 34377
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------