Provider Demographics
NPI:1528744307
Name:FORTNER, MIRANDA VERSACE (PHARMD)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:VERSACE
Last Name:FORTNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 FOOTHILLS MALL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801
Mailing Address - Country:US
Mailing Address - Phone:865-379-7899
Mailing Address - Fax:
Practice Address - Street 1:220 FOOTHILLS MALL DRIVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801
Practice Address - Country:US
Practice Address - Phone:865-379-7899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist