Provider Demographics
NPI:1487818571
Name:STONEBRIDGE APOTHECARY LLC
Entity Type:Organization
Organization Name:STONEBRIDGE APOTHECARY LLC
Other - Org Name:STONEBRIDGE APOTHECARY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HUETER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:721-608-1186
Mailing Address - Street 1:111 STONEBRIDGE BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2040
Mailing Address - Country:US
Mailing Address - Phone:731-410-6787
Mailing Address - Fax:731-410-6789
Practice Address - Street 1:111 STONEBRIDGE BLVD
Practice Address - Street 2:STE A
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2040
Practice Address - Country:US
Practice Address - Phone:731-410-6787
Practice Address - Fax:731-410-6789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45353336C0002X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4441464OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4441464OtherNCPDP PROVIDER IDENTIFICATION NUMBER