Healthcare Provider Details

I. General information

NPI: 1104997915
Provider Name (Legal Business Name): MARY FARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-2833
US

IV. Provider business mailing address

1875 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-2833
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-1461
  • Fax: 573-785-0831
Mailing address:
  • Phone: 573-785-1461
  • Fax: 573-785-0831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number029078
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: