MEDICARE: CHARLES WYATT THOMPSON DPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5623	TN

General Provider Information

NPI Number	:	1053582924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES WYATT THOMPSON DPH

Provider Business Mailing Address
First Line	:	5171 SAM JARED DR
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37130-1382
Country	:	US
Telephone Number	:	615-867-5912
Fax Number	:	615-867-5759

Provider Business Practice Location Address
First Line	:	5171 SAM JARED DR
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37130-1382
Country	:	US
Telephone Number	:	615-867-5912
Fax Number	:	615-867-5759

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	03/18/2008

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