Provider Demographics
NPI:1407492606
Name:DOERR, MARYA JANE
Entity Type:Individual
Prefix:
First Name:MARYA
Middle Name:JANE
Last Name:DOERR
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 1:620 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-9381
Mailing Address - Country:US
Mailing Address - Phone:765-778-4884
Mailing Address - Fax:765-778-5234
Practice Address - Street 1:620 E STATE ST
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-9381
Practice Address - Country:US
Practice Address - Phone:765-778-4884
Practice Address - Fax:765-778-5234
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017747A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist