Provider Demographics
NPI:1306920434
Name:BLUE FRONT DRUG, INC
Entity type:Organization
Organization Name:BLUE FRONT DRUG, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-967-2251
Mailing Address - Street 1:107 1ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-1643
Mailing Address - Country:US
Mailing Address - Phone:931-967-2251
Mailing Address - Fax:931-967-6646
Practice Address - Street 1:107 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398-1643
Practice Address - Country:US
Practice Address - Phone:931-967-2251
Practice Address - Fax:931-967-6646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN12043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9441063Medicaid
2088179OtherPK
TN4412007Medicaid
4412007OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4412007OtherOTHER ID NUMBER