Provider Demographics
NPI:1215128004
Name:COLE, MARCUS FAYNE JR
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:FAYNE
Last Name:COLE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 CUMBERLAND GAP PKWY
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-8232
Mailing Address - Country:US
Mailing Address - Phone:423-869-4707
Mailing Address - Fax:
Practice Address - Street 1:7030 CUMBERLAND GAP PKWY
Practice Address - Street 2:
Practice Address - City:HARROGATE
Practice Address - State:TN
Practice Address - Zip Code:37752-8232
Practice Address - Country:US
Practice Address - Phone:423-869-4707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000029419183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist