Provider Demographics
NPI:1841468790
Name:MAIN STREET FAMILY PHARMACY LLC
Entity type:Organization
Organization Name:MAIN STREET FAMILY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:731-627-2221
Mailing Address - Street 1:126 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERN
Mailing Address - State:TN
Mailing Address - Zip Code:38059-1527
Mailing Address - Country:US
Mailing Address - Phone:731-627-2221
Mailing Address - Fax:731-627-6152
Practice Address - Street 1:126 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWBERN
Practice Address - State:TN
Practice Address - Zip Code:38059-1527
Practice Address - Country:US
Practice Address - Phone:731-627-2221
Practice Address - Fax:731-627-6152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336H0001X
TN08953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454920Medicaid
4441313OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TN1454920Medicaid