Provider Demographics
NPI:1689729105
Name:MITCHUM, CARLISLE WEBB III
Entity type:Individual
Prefix:MR
First Name:CARLISLE
Middle Name:WEBB
Last Name:MITCHUM
Suffix:III
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MITCH
Other - Middle Name:
Other - Last Name:MITCHUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:34 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-4101
Mailing Address - Country:US
Mailing Address - Phone:931-289-4703
Mailing Address - Fax:
Practice Address - Street 1:18 SPRING ST
Practice Address - Street 2:
Practice Address - City:ERIN
Practice Address - State:TN
Practice Address - Zip Code:37061
Practice Address - Country:US
Practice Address - Phone:931-289-4231
Practice Address - Fax:931-289-4230
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist