Provider Demographics
NPI:1629194345
Name:PEARSON, MARY THERESE (R PH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESE
Last Name:PEARSON
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2435
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-2435
Mailing Address - Country:US
Mailing Address - Phone:530-832-0523
Mailing Address - Fax:530-283-1410
Practice Address - Street 1:493 MAIN ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:CA
Practice Address - Zip Code:95971-9120
Practice Address - Country:US
Practice Address - Phone:530-283-0480
Practice Address - Fax:530-283-1410
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH47093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV09698OtherNEVADA STATE LICENSE
CARPH47093OtherCA STATE LICENSE