Provider Demographics
NPI:1659667442
Name:MOBERG, MARY KATHRYN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:MOBERG
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 1:4795 W IRLO BRONSON MEMORIAL HWY
Mailing Address - Street 2:T-1918
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-5332
Mailing Address - Country:US
Mailing Address - Phone:407-594-0030
Mailing Address - Fax:407-594-0030
Practice Address - Street 1:4795 W IRLO BRONSON MEMORIAL HWY
Practice Address - Street 2:T-1918
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-5332
Practice Address - Country:US
Practice Address - Phone:407-594-0030
Practice Address - Fax:407-594-0030
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46339183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist