Provider Information for 1790770519
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GOOD OLD DRUGSTORE INC
Organization Subpart: NO
NPI: 1790770519
Last Updated: 2007-09-14
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1790770519 | ||||||||||||
| Enumeration Date | 2005-09-19 | ||||||||||||
| NPI Type | NPI-2 Organization | ||||||||||||
| Status | Active | ||||||||||||
| Authorized Official Information | Name: DAVID MALONE Title: PIC Phone: 8654979999 | ||||||||||||
| Mailing Address | PO BOX 98 WASHBURN, TN 37888-0098 United States Phone: | Fax: | ||||||||||||
| Primary Practice Address | 8295 HIGHWAY 131 WASHBURN, TN 37888 United States Phone: 865-497-9999 | Fax:865-497-9990 | ||||||||||||
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