Provider Demographics
NPI:1407536949
Name:MILLER, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MILLER
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 1:14672 N FRANK LLOYD WRIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2043
Mailing Address - Country:US
Mailing Address - Phone:602-541-7297
Mailing Address - Fax:
Practice Address - Street 1:14672 N FRANK LLOYD WRIGHT BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2043
Practice Address - Country:US
Practice Address - Phone:602-541-7297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS026512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist