Provider Demographics
NPI:1598304206
Name:HATHORN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HATHORN
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 1:107 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4738
Mailing Address - Country:US
Mailing Address - Phone:601-925-6343
Mailing Address - Fax:
Practice Address - Street 1:107 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4738
Practice Address - Country:US
Practice Address - Phone:601-925-6343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-27
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MST80721835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy