Provider Demographics
NPI:1215262670
Name:GUARDIAN PHARMACY OF TN ONE
Entity type:Organization
Organization Name:GUARDIAN PHARMACY OF TN ONE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:931-684-9987
Mailing Address - Street 1:GUARDIAN PHARMACY OF TENNESSEE ONE DEPT 2389
Mailing Address - Street 2:P.O. BOX 11407
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2389
Mailing Address - Country:US
Mailing Address - Phone:404-810-0089
Mailing Address - Fax:404-810-0094
Practice Address - Street 1:661 E LANE ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3437
Practice Address - Country:US
Practice Address - Phone:931-684-9987
Practice Address - Fax:931-684-9995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-02
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000004147332B00000X, 332BP3500X, 3336C0004X, 3336H0001X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G876440OtherLOCAL MEDICARE PART B
TN4276630OtherBCBS HIT
TN1520567Medicaid
TN103G876440OtherLOCAL MEDICARE PART B
TN4276630OtherBCBS HIT