Provider Demographics
NPI:1629328729
Name:ANDREASON, MALLORY L (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:L
Last Name:ANDREASON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-2415
Mailing Address - Country:US
Mailing Address - Phone:304-346-0829
Mailing Address - Fax:
Practice Address - Street 1:1701 4TH AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2415
Practice Address - Country:US
Practice Address - Phone:304-346-0829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-16
Last Update Date:2012-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007766183500000X
FLPS48006183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist