Provider Demographics
NPI:1639583040
Name:MARSHALL, MARY ELLEN ELLEN
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:ELLEN
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:39510 N GAVILAN PEAK PKWY
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-2777
Mailing Address - Country:US
Mailing Address - Phone:623-551-1031
Mailing Address - Fax:623-551-4924
Practice Address - Street 1:39510 N GAVILAN PEAK PKWY
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-2777
Practice Address - Country:US
Practice Address - Phone:623-551-1031
Practice Address - Fax:623-551-4924
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13508183500000X
TX31813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist