Healthcare Provider Details

I. General information

NPI: 1861545543
Provider Name (Legal Business Name): MARY DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WAI DOUGLAS RPH

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WESTAGE BUSINESS CTR DR
FISHKILL NY
12524-2264
US

IV. Provider business mailing address

19 ORCHARD PARK
POUGHKEEPSIE NY
12603-4839
US

V. Phone/Fax

Practice location:
  • Phone: 845-897-2905
  • Fax: 845-897-2908
Mailing address:
  • Phone: 845-849-3302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number357641
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: