Provider Demographics
NPI:1265047179
Name:ETHRIDGE, MABELLA B (PHARMD)
Entity type:Individual
Prefix:
First Name:MABELLA
Middle Name:B
Last Name:ETHRIDGE
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 1:401 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-1525
Mailing Address - Country:US
Mailing Address - Phone:936-544-8188
Mailing Address - Fax:
Practice Address - Street 1:401 N 4TH ST
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-1525
Practice Address - Country:US
Practice Address - Phone:936-544-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist