Provider Demographics
NPI:1922393065
Name:PRIDE, MARY R
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:PRIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:RICHARD
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2800 PALM ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79107-2056
Mailing Address - Country:US
Mailing Address - Phone:806-731-0593
Mailing Address - Fax:
Practice Address - Street 1:2800 PALM ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79107-2056
Practice Address - Country:US
Practice Address - Phone:806-731-0593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty