Provider Demographics
NPI:1578270880
Name:DATES, RAVEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RAVEN
Middle Name:
Last Name:DATES
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 1:9676 GRAYS LAKE CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7770
Mailing Address - Country:US
Mailing Address - Phone:901-679-3909
Mailing Address - Fax:
Practice Address - Street 1:4155 ELVIS PRESLEY BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-5810
Practice Address - Country:US
Practice Address - Phone:901-348-4642
Practice Address - Fax:901-348-4643
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41147183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist