Provider Demographics
NPI:1588721682
Name:JERRY D. LOWERY
Entity type:Organization
Organization Name:JERRY D. LOWERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LOWERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-338-2521
Mailing Address - Street 1:119 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:TN
Mailing Address - Zip Code:37307
Mailing Address - Country:US
Mailing Address - Phone:423-338-2521
Mailing Address - Fax:423-338-1092
Practice Address - Street 1:119 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:TN
Practice Address - Zip Code:37307-3864
Practice Address - Country:US
Practice Address - Phone:423-338-2521
Practice Address - Fax:423-338-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1328183500000X
TN25571183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3526590Medicaid