Provider Demographics
NPI:1194748566
Name:ANDERSON & HAILE DRUG STORE
Entity type:Organization
Organization Name:ANDERSON & HAILE DRUG STORE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TENEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:931-268-0233
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:GAINESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38562-0065
Mailing Address - Country:US
Mailing Address - Phone:931-268-0233
Mailing Address - Fax:931-268-2183
Practice Address - Street 1:101 WEST GORE AVE
Practice Address - Street 2:
Practice Address - City:GAINESBORO
Practice Address - State:TN
Practice Address - Zip Code:38562
Practice Address - Country:US
Practice Address - Phone:931-268-0233
Practice Address - Fax:931-268-2183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TN00000003783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4400557Medicaid
4400557OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6268660001Medicare NSC