Basic Information
| Provider Information | |||||||||
| NPI: | 1700550753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANCROFT | ||||||||
| FirstName: | ALEXA | ||||||||
| MiddleName: | NOELLE DODSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1114 TOMAHAWK CIR NW | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373123462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232849616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1114 W MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373034150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237451411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2021 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 45131 | TN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.