Provider Demographics
NPI:1982148565
Name:SMITH, MARK JR
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 VENICE RD SW
Mailing Address - Street 2:APT 3303
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-6203
Mailing Address - Country:US
Mailing Address - Phone:205-657-7131
Mailing Address - Fax:
Practice Address - Street 1:2850 VENICE RD SW
Practice Address - Street 2:APT 3303
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-6203
Practice Address - Country:US
Practice Address - Phone:205-657-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist