Provider Demographics
NPI:1821328774
Name:PHELPS, MARK C (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E CENTEX EXPY
Mailing Address - Street 2:WALGREENS #10711
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541
Mailing Address - Country:US
Mailing Address - Phone:254-526-4258
Mailing Address - Fax:254-526-8809
Practice Address - Street 1:1000 E CENTRAL TEXAS EXPY
Practice Address - Street 2:WALGREENS #10711
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541
Practice Address - Country:US
Practice Address - Phone:254-526-4258
Practice Address - Fax:254-526-8809
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45669183500000X
FLPS35094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist