Provider Demographics
NPI:1831272129
Name:MINNIS DRUG STORE INC
Entity type:Organization
Organization Name:MINNIS DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIEF PHARMICIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:CANTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPH PHARMACY
Authorized Official - Phone:423-586-4562
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37815-0369
Mailing Address - Country:US
Mailing Address - Phone:423-586-4562
Mailing Address - Fax:423-587-5537
Practice Address - Street 1:1250 TENNOVA MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-3120
Practice Address - Country:US
Practice Address - Phone:865-895-6072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000019753336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4409670OtherNABP
TN0685460001Medicare NSC