Provider Demographics
NPI:1316455157
Name:MEBANE, JON BRETT (DPH)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:BRETT
Last Name:MEBANE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SPRUCE ST N
Mailing Address - Street 2:
Mailing Address - City:BRUCETON
Mailing Address - State:TN
Mailing Address - Zip Code:38317-2034
Mailing Address - Country:US
Mailing Address - Phone:731-415-0258
Mailing Address - Fax:
Practice Address - Street 1:175 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:TN
Practice Address - Zip Code:38320-1621
Practice Address - Country:US
Practice Address - Phone:731-584-4711
Practice Address - Fax:731-584-5906
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8398183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN8398OtherSTATE OF TENNESSEE LISCENSE