Provider Demographics
NPI:1164162178
Name:REFAILOV, MARY LISA
Entity Type:Individual
Prefix:
First Name:MARY LISA
Middle Name:
Last Name:REFAILOV
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 1:29670 ELLENSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-8701
Mailing Address - Country:US
Mailing Address - Phone:541-247-4544
Mailing Address - Fax:541-247-2604
Practice Address - Street 1:29670 ELLENSBURG AVE
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-8701
Practice Address - Country:US
Practice Address - Phone:541-247-4544
Practice Address - Fax:541-247-2604
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist