Provider Demographics
NPI:1780967083
Name:FLOCKHART, MARY JO (RPH)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JO
Last Name:FLOCKHART
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:FEEHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:401 5TH ST W
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-1700
Mailing Address - Country:US
Mailing Address - Phone:507-645-9658
Mailing Address - Fax:507-645-9674
Practice Address - Street 1:401 5TH ST W
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-1700
Practice Address - Country:US
Practice Address - Phone:507-645-9658
Practice Address - Fax:507-645-9674
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116623-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist