Provider Demographics
NPI:1750935367
Name:PORTLAND CLINIC PHARMACY
Entity type:Organization
Organization Name:PORTLAND CLINIC PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:STINNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-323-5050
Mailing Address - Street 1:420 TN-52
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148
Mailing Address - Country:US
Mailing Address - Phone:615-909-4030
Mailing Address - Fax:615-909-6005
Practice Address - Street 1:420 TN-52
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148
Practice Address - Country:US
Practice Address - Phone:615-909-4030
Practice Address - Fax:615-909-6005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-31
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ054208Medicaid