Provider Demographics
NPI:1679594626
Name:NUTRITIONAL SUPPORT SERVICES
Entity type:Organization
Organization Name:NUTRITIONAL SUPPORT SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-890-2020
Mailing Address - Street 1:PO BOX 32249
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-2249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1329 HORAN DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-1939
Practice Address - Country:US
Practice Address - Phone:636-779-2700
Practice Address - Fax:636-779-2704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X
MO20040342393336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606172203Medicaid
2049057OtherPK