Provider Demographics
NPI:1437871704
Name:WYATT, MARY R (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:R
Last Name:WYATT
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:R
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2601 WOODSTONE DR
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2561
Mailing Address - Country:US
Mailing Address - Phone:573-718-7573
Mailing Address - Fax:
Practice Address - Street 1:3001 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8942
Practice Address - Country:US
Practice Address - Phone:573-772-7169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022032015183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist