Provider Demographics
NPI:1497136089
Name:GEORGE, MARY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:GEORGE
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 1:1561 HIDDENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-2817
Mailing Address - Country:US
Mailing Address - Phone:703-609-7271
Mailing Address - Fax:
Practice Address - Street 1:1561 HIDDENBROOK DR
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-2817
Practice Address - Country:US
Practice Address - Phone:703-609-7271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45316183500000X
MD14340183500000X
VA0202012266183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist