Provider Demographics
NPI:1962922435
Name:VANDERBILT HEALTH PHARMACY GROUP LLC
Entity type:Organization
Organization Name:VANDERBILT HEALTH PHARMACY GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MANFRED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-322-4775
Mailing Address - Street 1:718 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-2151
Mailing Address - Country:US
Mailing Address - Phone:888-666-4992
Mailing Address - Fax:615-242-1151
Practice Address - Street 1:718 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-2151
Practice Address - Country:US
Practice Address - Phone:888-666-4992
Practice Address - Fax:615-242-1151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCN.0003470333600000X
TN60123336S0011X
VT036.01341643336S0011X
MS16879/7.13336S0011X
OHNRP.022861300-033336S0011X
MO20180048783336S0011X
KYTN22913336S0011X
VA02140020423336S0011X
MN2655003336S0011X
WYNR-515113336S0011X
IN64002467A3336S0011X
GAPHNR0013963336S0011X
IL054.0207963336S0011X
MTPHA-MOP-LIC-524763336S0011X
COOSP.00071183336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ034038Medicaid
2170126OtherPK