Provider Demographics
NPI:1033406111
Name:MEDIPHARM INC.
Entity type:Organization
Organization Name:MEDIPHARM INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:NYANDAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:OTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-746-9631
Mailing Address - Street 1:295 S BELLEVUE BLVD
Mailing Address - Street 2:SUITE # 3
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-7517
Mailing Address - Country:US
Mailing Address - Phone:901-746-9631
Mailing Address - Fax:901-791-9292
Practice Address - Street 1:295 S BELLEVUE BLVD
Practice Address - Street 2:SUITE # 3
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7517
Practice Address - Country:US
Practice Address - Phone:901-746-9631
Practice Address - Fax:901-791-9292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-08
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN 16134363LF0000X
TN44D2021574246RP1900X
TNMD7664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1780980631OtherSPECIALTY PHARMACY
TN1942476528OtherRETAIL PHARMACY