Provider Demographics
NPI:1194957621
Name:TENNYSON, NOAH MATTHEW (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NOAH
Middle Name:MATTHEW
Last Name:TENNYSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3732 NAMEOKI RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-3714
Mailing Address - Country:US
Mailing Address - Phone:618-877-6880
Mailing Address - Fax:
Practice Address - Street 1:3732 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3714
Practice Address - Country:US
Practice Address - Phone:618-877-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007025602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist