Provider Demographics
NPI:1962746990
Name:EPSB LLC
Entity type:Organization
Organization Name:EPSB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-489-3582
Mailing Address - Street 1:PO BOX 737
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004-0737
Mailing Address - Country:US
Mailing Address - Phone:901-837-8801
Mailing Address - Fax:901-837-8802
Practice Address - Street 1:139 WESLEY REED DR STE F
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004-4918
Practice Address - Country:US
Practice Address - Phone:901-837-8801
Practice Address - Fax:901-837-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN000037803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153440OtherPK