Provider Demographics
NPI:1275229114
Name:JOHNSON, MALLORY DE
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:DE
Last Name:JOHNSON
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 1:992 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-4004
Mailing Address - Country:US
Mailing Address - Phone:601-754-0057
Mailing Address - Fax:
Practice Address - Street 1:82 MAIN ST W
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:MS
Practice Address - Zip Code:39653-9320
Practice Address - Country:US
Practice Address - Phone:601-384-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-12933183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist