Provider Demographics
NPI:1316109390
Name:MIDDLE TENNESSEE STATE UNIVERSITY
Entity type:Organization
Organization Name:MIDDLE TENNESSEE STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR OF PHCY
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:615-494-8888
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37132-0001
Mailing Address - Country:US
Mailing Address - Phone:615-494-8888
Mailing Address - Fax:615-494-8700
Practice Address - Street 1:1848 BLUE RAIDER DR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37132-0001
Practice Address - Country:US
Practice Address - Phone:615-494-8888
Practice Address - Fax:615-494-8700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN00000045313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095426OtherPK