Provider Demographics
NPI:1104869486
Name:STATE OF TENNESSEE STATE F & A PAYROLL
Entity type:Organization
Organization Name:STATE OF TENNESSEE STATE F & A PAYROLL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-532-6736
Mailing Address - Street 1:100 MOCCASIN BEND RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-4415
Mailing Address - Country:US
Mailing Address - Phone:423-785-3321
Mailing Address - Fax:423-785-3454
Practice Address - Street 1:100 MOCCASIN BEND RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-4415
Practice Address - Country:US
Practice Address - Phone:423-785-3321
Practice Address - Fax:423-785-3454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X
TNL2(16)M210510983336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2088533OtherPK