Basic Information
| Provider Information | |||||||||
| NPI: | 1588006555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLOUGHBY | ||||||||
| FirstName: | LANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2117 VICTORY GALLOP LN | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371288265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158187288 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1310 24TH AVE S | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372122637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274751 | ||||||||
| FaxNumber: | 6153216350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 07/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | 0000038444 | TN | Y | Pharmacy Service Providers | Pharmacy Technician |
No ID Information.