Provider Demographics
NPI:1215426325
Name:DEPUE, MISTY MASHAE
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:MASHAE
Last Name:DEPUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N ANDERSON LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-6926
Mailing Address - Country:US
Mailing Address - Phone:615-264-0078
Mailing Address - Fax:615-826-7971
Practice Address - Street 1:204 N ANDERSON LN
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-6926
Practice Address - Country:US
Practice Address - Phone:615-264-0078
Practice Address - Fax:615-826-7971
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist