Provider Demographics
NPI:1912398306
Name:CAMPBELL, MARY KATHERYN CAMPBELL
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERYN CAMPBELL
Last Name:CAMPBELL
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 1:5905 SHADY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-6828
Mailing Address - Country:US
Mailing Address - Phone:252-373-2990
Mailing Address - Fax:
Practice Address - Street 1:1000 SHOPPES AT MIDWAY DR
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7313
Practice Address - Country:US
Practice Address - Phone:919-388-6101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-07
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34927183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician