Provider Demographics
NPI:1144256538
Name:RENEGAR DRUG STORE
Entity type:Organization
Organization Name:RENEGAR DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:931-684-1933
Mailing Address - Street 1:629 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-3235
Mailing Address - Country:US
Mailing Address - Phone:931-684-1933
Mailing Address - Fax:931-684-8739
Practice Address - Street 1:629 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3235
Practice Address - Country:US
Practice Address - Phone:931-684-1933
Practice Address - Fax:931-684-8739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3544640Medicaid
TN3544640Medicaid