Provider Demographics
NPI:1336270537
Name:MCCORMICK, MARY C (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:SHAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 1037
Mailing Address - Street 2:101 RIVERSIDE DRIVE
Mailing Address - City:POPLAR
Mailing Address - State:MT
Mailing Address - Zip Code:59255-1037
Mailing Address - Country:US
Mailing Address - Phone:406-768-2153
Mailing Address - Fax:
Practice Address - Street 1:107 H ST E
Practice Address - Street 2:VERNE E GIBBS IHS CLINIC
Practice Address - City:POPLAR
Practice Address - State:MT
Practice Address - Zip Code:59255
Practice Address - Country:US
Practice Address - Phone:406-768-2153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND8HBY42Medicare PIN