Provider Demographics
NPI:1831521269
Name:WILLIS, MARY (PHARMD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19605 NE 130TH CIR
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-3904
Mailing Address - Country:US
Mailing Address - Phone:360-901-2842
Mailing Address - Fax:
Practice Address - Street 1:3800 SE 22ND AVE
Practice Address - Street 2:04004/RDS
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2918
Practice Address - Country:US
Practice Address - Phone:503-797-5082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0013605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist