Basic Information
Provider Information | |||||||||
NPI: | 1851493001 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOATRIGHT | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | CHER | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CASSELBERRY | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: | CHER | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHARMD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 4000 | ||||||||
Address2: | JAMES H. QUILLEN VA MEDICAL CENTER | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | TN | ||||||||
PostalCode: | 37684 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4239261171 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | BUILDING 160 DEPARTMENT OF PHARMACY | ||||||||
Address2: | JAMES H. QUILLEN VA MEDICAL CENTER | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | TN | ||||||||
PostalCode: | 37684 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4239261171 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2006 | ||||||||
LastUpdateDate: | 08/21/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5302031834 | MI | Y |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | 19271 | NC | N |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.