Provider Demographics
NPI:1528305471
Name:TATE, EBONY (PHARM D, BCPS, BCGP)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:PHARM D, BCPS, BCGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1602
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-1602
Mailing Address - Country:US
Mailing Address - Phone:480-213-9024
Mailing Address - Fax:502-405-5345
Practice Address - Street 1:325 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-4254
Practice Address - Country:US
Practice Address - Phone:480-213-9024
Practice Address - Fax:502-405-5345
Is Sole Proprietor?:No
Enumeration Date:2013-01-12
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023154183500000X
HIPH-3837183500000X
LAPST.020045183500000X
IDP6855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist