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NPI Code Detail

MEDICARE: DR. MAURICE DOUGLAS KISTNER D.PH

MEDICARE: DR. MAURICE DOUGLAS KISTNER D.PH
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
1183500000XPharmacist5496TN

General Provider Information

NPI Number : 1770708752
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MAURICE DOUGLAS KISTNER D.PH
Provider Business Mailing Address
First Line : 103 N SHADY ST
Second Line :
City : MOUNTAIN CITY
State : TN
Zip : 37683-1333
Country : US
Telephone Number : 423-727-5651
Fax Number : 423-727-0148
Provider Business Practice Location Address
First Line : 103 N SHADY ST
Second Line :
City : MOUNTAIN CITY
State : TN
Zip : 37683-1333
Country : US
Telephone Number : 423-727-5651
Fax Number : 423-727-0148
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/16/2007
Last Update Date : 07/08/2007

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