Healthcare Provider Details

I. General information

NPI: 1316613821
Provider Name (Legal Business Name): MARCUS MALLORY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N PROVIDENCE RD
COLUMBIA MO
65203-4373
US

IV. Provider business mailing address

811 E GREEN MEADOWS RD APT 210
COLUMBIA MO
65201-3747
US

V. Phone/Fax

Practice location:
  • Phone: 573-442-0194
  • Fax: 573-443-8253
Mailing address:
  • Phone: 573-205-6145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2021031841
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: