Provider Demographics
NPI:1861013781
Name:HAYWOOD, MARK ALLEN (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:HAYWOOD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4849 POLLACK AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-5750
Mailing Address - Country:US
Mailing Address - Phone:812-962-4664
Mailing Address - Fax:812-962-4660
Practice Address - Street 1:4849 POLLACK AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-5750
Practice Address - Country:US
Practice Address - Phone:812-962-4664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020577A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy