Organization
MOUNTAIN VALLEY RX 05 INC
Active
Organization
MOUNTAIN VALLEY RX 05 INC
Active
Other names
JEFFCO DRUG CENTER IN JEFFERSON CITY
Organization subpart
No
Provider details
NPI number
Authorized official
BEAU KISABETH (MANAGER)
(865) 388-3211
Entity
Organization
Contact information
Practice address
153 E BROADWAY BLVD, STE 103, JEFFERSON CITY, TN 37760-2517
(865) 471-5111
(865) 471-5199
Mailing address
PO BOX 385, DANDRIDGE, TN 37725-0385
(865) 475-9969
(865) 475-9901
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
3918
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4437364
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
01/23/2007
Last updated
03/30/2010
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