=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427654623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BCP1, LLC LONG TERM CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2020
-----------------------------------------------------
Last Update Date | 12/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2490 PARR AVE STE 9
-----------------------------------------------------
City | DYERSBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38024-2030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-285-0844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2490 PARR AVE STE 9B
-----------------------------------------------------
City | DYERSBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38024-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-285-0844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PHARMACIST
-----------------------------------------------------
Name | MARK BARRETT BROOKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 731-513-0882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------