Provider Demographics
NPI:1740514330
Name:DVORAK, MARY E (PHARMACIST)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:DVORAK
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HEALTH CENTER ROAD
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:SD
Mailing Address - Zip Code:57752-0540
Mailing Address - Country:US
Mailing Address - Phone:605-455-8227
Mailing Address - Fax:605-455-2808
Practice Address - Street 1:1000 HEALTH CENTER ROAD
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:SD
Practice Address - Zip Code:57752
Practice Address - Country:US
Practice Address - Phone:605-455-8226
Practice Address - Fax:605-455-1529
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10445183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10445OtherLICENSING STATE