=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255639985
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY KATHRYN FREEMAN-STAUFFER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2011
-----------------------------------------------------
Last Update Date | 04/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1405 N MAIN ST
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-4352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-539-9490
-----------------------------------------------------
Fax | 757-539-4181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1405 N MAIN ST
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-4352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-539-9490
-----------------------------------------------------
Fax | 757-539-4181
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202007475
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------