Provider Demographics
NPI:1710490891
Name:MORTAR AND PESTLE, LLC
Entity Type:Organization
Organization Name:MORTAR AND PESTLE, LLC
Other - Org Name:THE MEDICINE CABINET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:706-298-2714
Mailing Address - Street 1:300 MOOTY BRIDGE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-1881
Mailing Address - Country:US
Mailing Address - Phone:706-298-4935
Mailing Address - Fax:
Practice Address - Street 1:1704 ROANOKE RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3803
Practice Address - Country:US
Practice Address - Phone:706-298-4935
Practice Address - Fax:706-298-4934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-10
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0104033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy