Provider Demographics
NPI:1043760465
Name:WILLIS, MARY LAUREN ELIZABETH (PHARMD, BCOP)
Entity type:Individual
Prefix:DR
First Name:MARY LAUREN
Middle Name:ELIZABETH
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHARMD, BCOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 MOONCOIN WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6045
Mailing Address - Country:US
Mailing Address - Phone:859-806-8420
Mailing Address - Fax:
Practice Address - Street 1:4251 MOONCOIN WAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515
Practice Address - Country:US
Practice Address - Phone:859-806-8420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0159091835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology