Provider Demographics
NPI:1801170493
Name:PATE, BRUCE JOHNSON (DPH)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:JOHNSON
Last Name:PATE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E REELFOOT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5804
Mailing Address - Country:US
Mailing Address - Phone:731-884-1223
Mailing Address - Fax:731-884-3859
Practice Address - Street 1:700 E REELFOOT AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5804
Practice Address - Country:US
Practice Address - Phone:731-884-1223
Practice Address - Fax:731-884-3859
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6107183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist