Provider Demographics
NPI:1164190963
Name:ETHRIDGE, KATELIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATELIN
Middle Name:
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 PETERSON AVE S
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-5234
Mailing Address - Country:US
Mailing Address - Phone:912-383-6862
Mailing Address - Fax:
Practice Address - Street 1:813 PETERSON AVE S
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-5234
Practice Address - Country:US
Practice Address - Phone:912-383-6862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028987183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist