=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558721233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARDEMAN COUNTY COMMUNITY HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2016
-----------------------------------------------------
Last Update Date | 02/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 NUCKOLLS RD
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38008-1599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-658-5294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 629 NUCKOLLS RD
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38008-1599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-658-5294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | LINDA LOVELACE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 731-658-5294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PD11747
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 6909
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5764
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------