Provider Demographics
NPI:1215176201
Name:PROMISECARE PHARMACY LLC
Entity type:Organization
Organization Name:PROMISECARE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:BABI
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:615-915-5266
Mailing Address - Street 1:605 BAKERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-2657
Mailing Address - Country:US
Mailing Address - Phone:615-915-5266
Mailing Address - Fax:305-222-7221
Practice Address - Street 1:605 BAKERTOWN RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-2657
Practice Address - Country:US
Practice Address - Phone:615-915-5266
Practice Address - Fax:305-222-7221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336M0002X, 3336M0003X, 3336S0011X
TN00000046193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1513392Medicaid
2118982OtherPK