Provider Demographics
NPI:1013502707
Name:CHAPMAN, MALLORY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:CHAPMAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 MARGETTE WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2964
Mailing Address - Country:US
Mailing Address - Phone:208-569-3200
Mailing Address - Fax:
Practice Address - Street 1:1450 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5131
Practice Address - Country:US
Practice Address - Phone:208-359-2814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP9192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP9192Medicaid