Provider Demographics
NPI:1760476345
Name:FORT, MARY ANN (RPH)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:FORT
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 1:2700 LEAFIELD TER
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-6040
Mailing Address - Country:US
Mailing Address - Phone:804-897-0686
Mailing Address - Fax:
Practice Address - Street 1:400 LIBBIE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2616
Practice Address - Country:US
Practice Address - Phone:804-285-8619
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist