Provider Demographics
NPI:1205290186
Name:ALLEN, MARY ALICE (RPH)
Entity type:Individual
Prefix:MRS
First Name:MARY ALICE
Middle Name:
Last Name:ALLEN
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 1:1012 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3730
Mailing Address - Country:US
Mailing Address - Phone:203-488-1631
Mailing Address - Fax:203-488-4089
Practice Address - Street 1:1012 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3730
Practice Address - Country:US
Practice Address - Phone:203-488-1631
Practice Address - Fax:203-488-4089
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24875183500000X
CT7996183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist