Provider Demographics
NPI:1225792989
Name:WILLINGHAM, MARCUS ALLEN
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:ALLEN
Last Name:WILLINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2352 W ALTA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5326
Mailing Address - Country:US
Mailing Address - Phone:619-288-0671
Mailing Address - Fax:
Practice Address - Street 1:554 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6019
Practice Address - Country:US
Practice Address - Phone:480-969-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS0255341835P2201X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care