Provider Demographics
NPI:1023243672
Name:CLARKSVILLE PHARMACY I LLC
Entity type:Organization
Organization Name:CLARKSVILLE PHARMACY I LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-330-8485
Mailing Address - Street 1:4112 BALDWIN ARBOR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2412
Mailing Address - Country:US
Mailing Address - Phone:931-802-5386
Mailing Address - Fax:931-802-5389
Practice Address - Street 1:801 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-2909
Practice Address - Country:US
Practice Address - Phone:931-802-5386
Practice Address - Fax:931-802-5389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4647333600000X
KYTN15673336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120310OtherPK
KY7100199100Medicaid
TN1515313Medicaid
2120310OtherPK