Provider Demographics
NPI:1194812446
Name:TRITENN LLC
Entity type:Organization
Organization Name:TRITENN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:423-579-8400
Mailing Address - Street 1:PO BOX 9205
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9205
Mailing Address - Country:US
Mailing Address - Phone:423-477-3847
Mailing Address - Fax:423-477-4392
Practice Address - Street 1:208 SUNCREST ST
Practice Address - Street 2:STE 1
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-3494
Practice Address - Country:US
Practice Address - Phone:423-477-3847
Practice Address - Fax:423-477-4392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC0010073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0149630001Medicaid
0149630001Medicare ID - Type Unspecified