Provider Demographics
NPI:1447625363
Name:DYER STATION PHARMACY LLC
Entity type:Organization
Organization Name:DYER STATION PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-692-3578
Mailing Address - Street 1:2017 S COLLEGE ST STE B
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-3934
Mailing Address - Country:US
Mailing Address - Phone:731-855-0500
Mailing Address - Fax:731-855-0400
Practice Address - Street 1:2017 S COLLEGE ST STE B
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-3934
Practice Address - Country:US
Practice Address - Phone:731-855-0500
Practice Address - Fax:731-855-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
TN00000057043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155145OtherPK
TNQ033472Medicaid