Provider Demographics
NPI:1053743617
Name:BAGWELL, AUTUMN DAWN (PHARMD)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:DAWN
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 ACKLEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1106
Mailing Address - Country:US
Mailing Address - Phone:931-217-4358
Mailing Address - Fax:
Practice Address - Street 1:1310 24TH AVE S
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-2637
Practice Address - Country:US
Practice Address - Phone:931-217-4358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17380183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist