Provider Demographics
NPI:1861545543
Name:DOUGLAS, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WAI
Other - Middle Name:
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:19 ORCHARD PARK
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-4839
Mailing Address - Country:US
Mailing Address - Phone:845-849-3302
Mailing Address - Fax:
Practice Address - Street 1:200 WESTAGE BUSINESS CTR DR
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-2264
Practice Address - Country:US
Practice Address - Phone:845-897-2905
Practice Address - Fax:845-897-2908
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY357641183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist