Healthcare Provider Details

I. General information

NPI: 1033713169
Provider Name (Legal Business Name): RONALD ETHAN PRATER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 E CEDAR ST
BRISTOL TN
37620-3928
US

IV. Provider business mailing address

308 E CEDAR ST
BRISTOL TN
37620-3928
US

V. Phone/Fax

Practice location:
  • Phone: 423-968-7983
  • Fax:
Mailing address:
  • Phone: 423-968-7983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number0202216140
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number41545
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: