Provider Demographics
NPI:1861751059
Name:MALLORY, MARCUS ALAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:ALAN
Last Name:MALLORY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5434 SE 107TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420-3295
Mailing Address - Country:US
Mailing Address - Phone:352-208-6853
Mailing Address - Fax:
Practice Address - Street 1:10393-97 SE HWY 441-27
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420
Practice Address - Country:US
Practice Address - Phone:352-307-8260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist