Provider Demographics
NPI:1912509837
Name:FOOTE, MARY ALICE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:FOOTE
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 1:2428 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-2310
Mailing Address - Country:US
Mailing Address - Phone:904-583-8952
Mailing Address - Fax:
Practice Address - Street 1:870 SADLER RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4752
Practice Address - Country:US
Practice Address - Phone:904-261-0836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43482183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist