Provider Demographics
NPI:1801881776
Name:TUCKER, TONY L (D PH)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:M
Credentials:D PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 OAK DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-2210
Mailing Address - Country:US
Mailing Address - Phone:731-986-4173
Mailing Address - Fax:731-986-2171
Practice Address - Street 1:132 OAK DR
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-2210
Practice Address - Country:US
Practice Address - Phone:731-986-4173
Practice Address - Fax:731-986-2171
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3912948Medicare PIN