Provider Demographics
NPI:1528110897
Name:SELLS, TONY DALE (DPH)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:DALE
Last Name:SELLS
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 1:330 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2440
Mailing Address - Country:US
Mailing Address - Phone:931-528-8479
Mailing Address - Fax:
Practice Address - Street 1:330 N OAK AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2440
Practice Address - Country:US
Practice Address - Phone:931-528-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3544998Medicaid
TN4418100OtherNCPDP
TN4418100OtherNCPDP
TN3544998Medicaid