Provider Demographics
NPI:1205437944
Name:CAROTHERS, NATHAN WILLIAM JR
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:WILLIAM
Last Name:CAROTHERS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 COUNTY ROAD 614
Mailing Address - Street 2:
Mailing Address - City:EARLY
Mailing Address - State:TX
Mailing Address - Zip Code:76802-3440
Mailing Address - Country:US
Mailing Address - Phone:325-647-9221
Mailing Address - Fax:
Practice Address - Street 1:2207 S BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRADY
Practice Address - State:TX
Practice Address - Zip Code:76825-7550
Practice Address - Country:US
Practice Address - Phone:325-597-3456
Practice Address - Fax:325-597-1223
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist