Provider Demographics
NPI:1982130290
Name:PHARMACY AT FAMILY MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:PHARMACY AT FAMILY MEDICAL CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUGHTRY
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:615-215-6979
Mailing Address - Street 1:300 N CONGRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37166-2704
Mailing Address - Country:US
Mailing Address - Phone:615-215-6979
Mailing Address - Fax:615-597-6337
Practice Address - Street 1:300 N CONGRESS BLVD
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37166-2704
Practice Address - Country:US
Practice Address - Phone:615-215-6979
Practice Address - Fax:615-597-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-05
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN00000061743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175748OtherPK
TNQ034972Medicaid