Provider Demographics
NPI:1861585218
Name:MED CENTER PHARMACY LLC
Entity type:Organization
Organization Name:MED CENTER PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-272-8104
Mailing Address - Street 1:900 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-2448
Mailing Address - Country:US
Mailing Address - Phone:423-272-8104
Mailing Address - Fax:423-272-0282
Practice Address - Street 1:900 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-2448
Practice Address - Country:US
Practice Address - Phone:423-272-8104
Practice Address - Fax:423-272-0282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN17063336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095045OtherPK
5140060001Medicare NSC