Provider Demographics
NPI:1720159569
Name:ALLEN, MARY EDITH
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:EDITH
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 SOUTHERN COMFORT DR
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:SC
Mailing Address - Zip Code:29388-8102
Mailing Address - Country:US
Mailing Address - Phone:864-486-8069
Mailing Address - Fax:864-476-6012
Practice Address - Street 1:345 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-1867
Practice Address - Country:US
Practice Address - Phone:864-476-2111
Practice Address - Fax:864-476-6012
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC005709183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist