Provider Demographics
NPI:1053963975
Name:MAYNARDVILLE DRUG LLC
Entity type:Organization
Organization Name:MAYNARDVILLE DRUG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:SIMMONS
Authorized Official - Last Name:HALFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:865-278-7895
Mailing Address - Street 1:PO BOX 990
Mailing Address - Street 2:
Mailing Address - City:NEW TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37824-0990
Mailing Address - Country:US
Mailing Address - Phone:865-278-7895
Mailing Address - Fax:
Practice Address - Street 1:2975 MAYNARDVILLE HWY
Practice Address - Street 2:
Practice Address - City:MAYNARDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37807
Practice Address - Country:US
Practice Address - Phone:865-658-5353
Practice Address - Fax:865-658-5354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy