=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952496804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PULMONAIRE SERVICE PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 06/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 MCCALLIE AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37403-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-265-3333
-----------------------------------------------------
Fax | 426-266-9254
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821 MCCALLIE AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37403-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-265-3333
-----------------------------------------------------
Fax | 426-266-9254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF PHARMACIST
-----------------------------------------------------
Name | STEPHEN WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-265-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2054
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------