Provider Demographics
NPI:1295949972
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:FANEUIL
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-549-5266
Mailing Address - Street 1:1522 CHEROKEE TRL
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-2205
Mailing Address - Country:US
Mailing Address - Phone:865-546-5266
Mailing Address - Fax:865-594-8919
Practice Address - Street 1:810 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-3285
Practice Address - Country:US
Practice Address - Phone:423-798-1749
Practice Address - Fax:423-798-1755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4440854OtherNCPDP