NPIMap

Organization Active NPI

Mountain Valley RX 05 Inc

  • Community/Retail Pharmacy
  • Jefferson City, TN
National Provider Identifier
1043364490
Registry record updated Mar 30, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
3918 Issued in TN
Legal business name
MOUNTAIN VALLEY RX 05 INC
Practice address
153 E Broadway Blvd
Ste 103
Jefferson City, TN 37760-2517
Phone
(865) 471-5111
Fax
(865) 471-5199
NPI assigned
Jan 23, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 30, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Beau Kisabeth
Title
Manager
Phone
(865) 388-3211

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X 3918 TN Primary

Addresses

Primary practice location

153 E Broadway Blvd
Ste 103
Jefferson City, TN 37760-2517

Mailing address

PO Box 385
Dandridge, TN 37725-0385
Phone (865) 475-9969

Other identifiers 1

IdentifierTypeStateIssuer
4437364OtherNCPDP PROVIDER IDENTIFICATION NUMBER

Other names 1

  • JEFFCO DRUG CENTER IN JEFFERSON CITY Doing business as

National Provider Directory

National Provider Directory

Locations

153 E Broadway Blvd
#103
Jefferson City, TN 37760
Phone (865) 471-5111

Practitioners & affiliated clinicians

Practitioners 25

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 25

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169510400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1269907200000",
    "number": "1043364490",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 385",
            "city": "DANDRIDGE",
            "state": "TN",
            "postal_code": "377250385",
            "telephone_number": "865-475-9969",
            "fax_number": "865-475-9901"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "153 E BROADWAY BLVD",
            "address_2": "STE 103",
            "city": "JEFFERSON CITY",
            "state": "TN",
            "postal_code": "377602517",
            "telephone_number": "865-471-5111",
            "fax_number": "865-471-5199"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN VALLEY RX 05 INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-23",
        "last_updated": "2010-03-30",
        "status": "A",
        "authorized_official_last_name": "KISABETH",
        "authorized_official_first_name": "BEAU",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "865-388-3211"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "TN",
            "license": "3918",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "4437364",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "JEFFCO DRUG CENTER IN JEFFERSON CITY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jefferson City, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 30, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.