Active NPI
Mabella B Ethridge, PHARMD
- Pharmacist
- Crockett, TX
National Provider Identifier
1265047179
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 63315
- Practice address
- 401 N 4TH St
Crockett, TX 75835-1525 - Phone
- (936) 544-8188
- NPI assigned
- Sep 9, 2020
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 63315 | TX | Primary |
Addresses
Primary practice location
401 N 4TH St
Crockett, TX 75835-1525
Mailing address
401 N 4TH St
Crockett, TX 75835-1525
Phone (936) 544-8188
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Pharmacy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 63315 | TX | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1599609600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1649980800000",
"number": "1265047179",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "401 N 4TH ST",
"city": "CROCKETT",
"state": "TX",
"postal_code": "758351525",
"telephone_number": "936-544-8188"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "401 N 4TH ST",
"city": "CROCKETT",
"state": "TX",
"postal_code": "758351525",
"telephone_number": "936-544-8188"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ETHRIDGE",
"first_name": "MABELLA",
"middle_name": "B",
"credential": "PHARMD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2020-09-09",
"last_updated": "2022-04-15",
"certification_date": "2022-04-15",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "TX",
"license": "63315",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Crockett, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.