Basic Information
Provider Information | |||||||||
NPI: | 1902961113 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | C MICHAEL JONES MDPC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JONES PROFESSIONAL BLDG PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7710 WOLF RIVER CIR | ||||||||
Address2: |   | ||||||||
City: | GERMANTOWN | ||||||||
State: | TN | ||||||||
PostalCode: | 381381734 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9016855969 | ||||||||
FaxNumber: | 9016656424 | ||||||||
Practice Location | |||||||||
Address1: | 7710 WOLF RIVER CIR | ||||||||
Address2: |   | ||||||||
City: | GERMANTOWN | ||||||||
State: | TN | ||||||||
PostalCode: | 381381734 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9016855969 | ||||||||
FaxNumber: | 9016656424 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2006 | ||||||||
LastUpdateDate: | 06/30/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCLURE | ||||||||
AuthorizedOfficialFirstName: | ASHLEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHARM MGR | ||||||||
AuthorizedOfficialTelephone: | 9016855969 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 0000003590 | TN | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 4434798A | 05 | TN |   | MEDICAID | 4434798 | 01 |   | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |