Provider Demographics
NPI:1174980262
Name:MORTAR & PESTLE, LLC
Entity type:Organization
Organization Name:MORTAR & PESTLE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:
Authorized Official - Phone:706-298-2714
Mailing Address - Street 1:1194 WARM SPRINGS HWY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31816
Mailing Address - Country:US
Mailing Address - Phone:706-846-2002
Mailing Address - Fax:706-846-2161
Practice Address - Street 1:1194 WARM SPRINGS HWY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:GA
Practice Address - Zip Code:31816
Practice Address - Country:US
Practice Address - Phone:706-846-2002
Practice Address - Fax:706-846-2161
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MORTAR AND PESTLE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-21
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
GAPHRE010202333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000453384AMedicaid
2155789OtherPK