Provider Demographics
NPI:1598352916
Name:FENN, MARY JEANNE (RPH)
Entity Type:Individual
Prefix:
First Name:MARY JEANNE
Middle Name:
Last Name:FENN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 CROSSWAYS PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2055
Mailing Address - Country:US
Mailing Address - Phone:516-249-7436
Mailing Address - Fax:516-249-7437
Practice Address - Street 1:415 CROSSWAYS PARK DR STE B
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2055
Practice Address - Country:US
Practice Address - Phone:516-249-7436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist