Provider Demographics
NPI:1639436660
Name:POWELL, MARY BOSEMAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BOSEMAN
Last Name:POWELL
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 1:77 NEALY AVENUE
Mailing Address - Street 2:633D MEDICAL GROUP
Mailing Address - City:JOINT BASE LANGLEY-EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2040
Mailing Address - Country:US
Mailing Address - Phone:757-225-7630
Mailing Address - Fax:
Practice Address - Street 1:77 NEALY AVENUE
Practice Address - Street 2:633D MEDICAL GROUP
Practice Address - City:JOINT BASE LANGLEY-EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-225-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207258183500000X
NC17996183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist