Provider Demographics
NPI:1144368218
Name:PETTIS, JEFFREY ALAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:PETTIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 ASA ST
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37876-2912
Mailing Address - Country:US
Mailing Address - Phone:865-429-7623
Mailing Address - Fax:
Practice Address - Street 1:250 MIDDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-3944
Practice Address - Country:US
Practice Address - Phone:865-453-5160
Practice Address - Fax:865-453-1946
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21927183500000X
GA22065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist