Provider Demographics
NPI:1972893634
Name:COMMUNITY PHARMACY LLC
Entity type:Organization
Organization Name:COMMUNITY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:AFAMEFUNA
Authorized Official - Last Name:OKONKWO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:267-809-1401
Mailing Address - Street 1:1805 N JACKSON ST STE 8
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-1821
Mailing Address - Country:US
Mailing Address - Phone:931-571-8644
Mailing Address - Fax:931-571-8706
Practice Address - Street 1:1805 N JACKSON ST STE 8
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2275
Practice Address - Country:US
Practice Address - Phone:931-571-8644
Practice Address - Fax:931-571-8706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN342223336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6608000001Medicare NSC