Provider Demographics
NPI:1538295464
Name:MORTAR AND PESTLE INVESTMENTS
Entity Type:Organization
Organization Name:MORTAR AND PESTLE INVESTMENTS
Other - Org Name:YATES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-569-5100
Mailing Address - Street 1:5404 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:FL
Mailing Address - Zip Code:32445-3128
Mailing Address - Country:US
Mailing Address - Phone:850-569-5100
Mailing Address - Fax:850-569-5170
Practice Address - Street 1:5404 10TH ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:FL
Practice Address - Zip Code:32445-3128
Practice Address - Country:US
Practice Address - Phone:850-569-5100
Practice Address - Fax:850-569-5170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH222923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031789600Medicaid
FL019398500Medicaid
2160150OtherPK