Provider Demographics
NPI:1023572732
Name:WOODALL, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WOODALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HARVEST HILL RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:770 ROOSEVELT TRL
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5300
Practice Address - Country:US
Practice Address - Phone:207-892-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR47099183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist