Provider Demographics
NPI:1427288950
Name:MORTAR AND PESTLE
Entity type:Organization
Organization Name:MORTAR AND PESTLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-526-2446
Mailing Address - Street 1:2708 N 4TH ST STE C-2
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1829
Mailing Address - Country:US
Mailing Address - Phone:928-526-2446
Mailing Address - Fax:928-526-2245
Practice Address - Street 1:2708 N 4TH ST STE C-2
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1829
Practice Address - Country:US
Practice Address - Phone:928-526-2446
Practice Address - Fax:928-526-2245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
AZY0051403336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0356279OtherNCPDP PROVIDER IDENTIFICATION NUMBER