Provider Demographics
NPI:1497107817
Name:TABOR, MARY M
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:TABOR
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 1:322 STEWART DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-9481
Mailing Address - Country:US
Mailing Address - Phone:662-803-0087
Mailing Address - Fax:662-773-9951
Practice Address - Street 1:322 STEWART DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-9481
Practice Address - Country:US
Practice Address - Phone:662-803-0087
Practice Address - Fax:662-773-9951
Is Sole Proprietor?:No
Enumeration Date:2016-07-09
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE06973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist