Provider Demographics
NPI:1902811557
Name:HILLCREST DRUG STORE INC
Entity Type:Organization
Organization Name:HILLCREST DRUG STORE INC
Other - Org Name:HILLCREST DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-926-0084
Mailing Address - Street 1:714 W MARKET ST STE 103
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5483
Mailing Address - Country:US
Mailing Address - Phone:423-926-6231
Mailing Address - Fax:423-926-0084
Practice Address - Street 1:714 W MARKET ST STE 103
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5483
Practice Address - Country:US
Practice Address - Phone:423-926-6231
Practice Address - Fax:423-926-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN04773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3551938Medicaid
2095599OtherPK
2095599OtherPK