=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699086488
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY PHILLIP DEBUHR JR. DPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2010
-----------------------------------------------------
Last Update Date | 06/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11927 KINGSTON PIKE
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37934-4602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-671-0932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12807 HEATHLAND DR
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37934-4445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-966-5749
-----------------------------------------------------
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 | C-6540
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------