Basic Information
| Provider Information | |||||||||
| NPI: | 1750776464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEWELL | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234336039 | ||||||||
| FaxNumber: | 4234336060 | ||||||||
| Practice Location | |||||||||
| Address1: | 917 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234396464 | ||||||||
| FaxNumber: | 4234397118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2015 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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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 | 183500000X | 26026116A | IN | N | Pharmacy Service Providers | Pharmacist | 183500000X | 26010 | NC | N | Pharmacy Service Providers | Pharmacist | 183500000X | 41554 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
No ID Information.