Provider Demographics
NPI:1831493121
Name:MALLORY, TYRA INEZ (RPH)
Entity Type:Individual
Prefix:MISS
First Name:TYRA
Middle Name:INEZ
Last Name:MALLORY
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 1:3830 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-5841
Mailing Address - Country:US
Mailing Address - Phone:202-291-0892
Mailing Address - Fax:202-291-3462
Practice Address - Street 1:3830 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5841
Practice Address - Country:US
Practice Address - Phone:202-291-0892
Practice Address - Fax:202-291-3462
Is Sole Proprietor?:No
Enumeration Date:2010-12-31
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPHA2744183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist