Provider Demographics
NPI:1629808027
Name:SIMMONS, DEBERRIAN (PHARMD)
Entity type:Individual
Prefix:
First Name:DEBERRIAN
Middle Name:
Last Name:SIMMONS
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 1:3804 MEMORIAL BLVD APT 12
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-3500
Mailing Address - Country:US
Mailing Address - Phone:423-491-2224
Mailing Address - Fax:
Practice Address - Street 1:5104 BOBBY HICKS HWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-6217
Practice Address - Country:US
Practice Address - Phone:423-477-3372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48412183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist