Provider Demographics
NPI:1134313554
Name:MULBERRY STREET PHARMACY LLC
Entity Type:Organization
Organization Name:MULBERRY STREET PHARMACY LLC
Other - Org Name:MULBERRY STREET PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JOESPH
Authorized Official - Middle Name:
Authorized Official - Last Name:RATLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:865-458-4586
Mailing Address - Street 1:916 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LOUDON
Mailing Address - State:TN
Mailing Address - Zip Code:37774-1311
Mailing Address - Country:US
Mailing Address - Phone:865-458-4586
Mailing Address - Fax:865-458-4545
Practice Address - Street 1:916 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:LOUDON
Practice Address - State:TN
Practice Address - Zip Code:37774-1311
Practice Address - Country:US
Practice Address - Phone:865-458-4586
Practice Address - Fax:865-458-4545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN44313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4440602OtherNCPDP PROVIDER IDENTIFICATION NUMBER