Provider Demographics
NPI:1902363385
Name:JODON, MARY D
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:JODON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 COOPER MILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-7415
Mailing Address - Country:US
Mailing Address - Phone:404-518-9996
Mailing Address - Fax:
Practice Address - Street 1:3338 WRIGHTSBORO RD.
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909
Practice Address - Country:US
Practice Address - Phone:404-518-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH027550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist