MEDICARE: MS. MARY KATHERINE WHEATLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	P3857	ID
2	183500000X	Pharmacist	6366	OR

General Provider Information

NPI Number	:	1174778849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY KATHERINE WHEATLEY

Provider Business Mailing Address
First Line	:	728 SW 4TH AVE
Second Line	:
City	:	ONTARIO
State	:	OR
Zip	:	97914-2626
Country	:	US
Telephone Number	:	541-889-3390
Fax Number	:	541-889-4488

Provider Business Practice Location Address
First Line	:	728 SW 4TH AVE
Second Line	:
City	:	ONTARIO
State	:	OR
Zip	:	97914-2626
Country	:	US
Telephone Number	:	541-889-3390
Fax Number	:	541-889-4488

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2008
Last Update Date	:	11/22/2008

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