Provider Demographics
NPI:1417699471
Name:SOUL APOTHECARY, LLC
Entity Type:Organization
Organization Name:SOUL APOTHECARY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINDABLE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:618-292-8964
Mailing Address - Street 1:306 EMILY CIR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1301
Mailing Address - Country:US
Mailing Address - Phone:618-292-8964
Mailing Address - Fax:
Practice Address - Street 1:787 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1960
Practice Address - Country:US
Practice Address - Phone:618-292-8964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health