Provider Demographics
NPI:1407143753
Name:MALLORY, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MALLORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PRECINCT LINE RD
Mailing Address - Street 2:T-1766
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-3828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 PRECINCT LINE RD
Practice Address - Street 2:T-1766
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-3828
Practice Address - Country:US
Practice Address - Phone:817-282-8917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist