Provider Demographics
NPI:1952087702
Name:STILL, MALLORY BENTLEY (PHARMD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:BENTLEY
Last Name:STILL
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 1:279 N BROAD ST STE B
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-2589
Mailing Address - Country:US
Mailing Address - Phone:770-867-8812
Mailing Address - Fax:
Practice Address - Street 1:279 N BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2589
Practice Address - Country:US
Practice Address - Phone:770-867-9072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist