Provider Demographics
NPI:1053582924
Name:THOMPSON, CHARLES WYATT (DPH)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WYATT
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5171 SAM JARED DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-1382
Mailing Address - Country:US
Mailing Address - Phone:615-867-5912
Mailing Address - Fax:615-867-5759
Practice Address - Street 1:5171 SAM JARED DR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-1382
Practice Address - Country:US
Practice Address - Phone:615-867-5912
Practice Address - Fax:615-867-5759
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5623183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist