MEDICARE: MRS. MALLORIE SANDERS WILLIS PHARMD

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	23454	NC

General Provider Information

NPI Number	:	1922493766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MALLORIE SANDERS WILLIS PHARMD

Provider Business Mailing Address
First Line	:	PO BOX 250
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28541-0250
Country	:	US
Telephone Number	:	910-347-5185
Fax Number	:	910-347-9298

Provider Business Practice Location Address
First Line	:	3060 RICHLANDS HWY
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-2926
Country	:	US
Telephone Number	:	910-455-9222
Fax Number	:	910-938-2221

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

Provider Enumeration Date	:	03/30/2015
Last Update Date	:	03/30/2015

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