Provider Demographics
NPI:1063743904
Name:BRETTHAVEN INC
Entity type:Organization
Organization Name:BRETTHAVEN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-537-3211
Mailing Address - Street 1:263 HAVEN LN
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-5756
Mailing Address - Country:US
Mailing Address - Phone:931-537-6782
Mailing Address - Fax:
Practice Address - Street 1:606 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-5325
Practice Address - Country:US
Practice Address - Phone:931-537-3211
Practice Address - Fax:931-537-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336H0001X, 3336C0004X, 333600000X, 3336N0007X
TN47403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336N0007XSuppliersPharmacyNuclear Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123391OtherPK