Provider Demographics
NPI:1528180833
Name:MOONEY'S PHARMACY, INC.
Entity type:Organization
Organization Name:MOONEY'S PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:423-926-3337
Mailing Address - Street 1:1115 N ROAN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-3901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 N ROAN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-3901
Practice Address - Country:US
Practice Address - Phone:423-926-3337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOONEY'S PHARMACY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-06
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN887332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454962Medicaid
TN4134540OtherBLUE CROSS BLUE SHIELD
TN5340000001Medicare NSC