Provider Demographics
NPI:1528342110
Name:BOUTTE, NATHANIEL STUART (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:STUART
Last Name:BOUTTE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HERITAGE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-7478
Mailing Address - Country:US
Mailing Address - Phone:901-219-9732
Mailing Address - Fax:
Practice Address - Street 1:4154 ELVIS PRESLEY BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-5811
Practice Address - Country:US
Practice Address - Phone:901-398-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29507183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist