Provider Demographics
NPI:1639623721
Name:DEMOTT, MALLORY (RPH)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:
Last Name:DEMOTT
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 1:13775 US HIGHWAY 19 S
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5398
Mailing Address - Country:US
Mailing Address - Phone:229-228-6419
Mailing Address - Fax:
Practice Address - Street 1:6615 MAHAN DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-1400
Practice Address - Country:US
Practice Address - Phone:850-878-5559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-07
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55030183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist