=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265806350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RITE AID PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2015
-----------------------------------------------------
Last Update Date | 11/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 S MAIN ST
-----------------------------------------------------
City | GOODLETTSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37072-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-851-5700
-----------------------------------------------------
Fax | 615-851-1611
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 S MAIN ST
-----------------------------------------------------
City | GOODLETTSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37072-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-851-5700
-----------------------------------------------------
Fax | 615-851-1611
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF PHARMACIST
-----------------------------------------------------
Name | SIMON IGHO IDIARE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-852-6133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 0000011542
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------