Healthcare Provider Details

I. General information

NPI: 1487818571
Provider Name (Legal Business Name): STONEBRIDGE APOTHECARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 STONEBRIDGE BLVD STE A
JACKSON TN
38305-2040
US

IV. Provider business mailing address

111 STONEBRIDGE BLVD STE A
JACKSON TN
38305-2040
US

V. Phone/Fax

Practice location:
  • Phone: 731-410-6787
  • Fax: 731-410-6789
Mailing address:
  • Phone: 731-410-6787
  • Fax: 731-410-6789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number4535
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID HUETER
Title or Position: OWNER
Credential: RPH
Phone: 721-608-1186