Provider Demographics
NPI:1871117903
Name:KEGLOVITS, MARY CHRISTINE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
Last Name:KEGLOVITS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SMETHPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16749-1139
Mailing Address - Country:US
Mailing Address - Phone:814-887-5375
Mailing Address - Fax:814-887-5393
Practice Address - Street 1:313 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SMETHPORT
Practice Address - State:PA
Practice Address - Zip Code:16749-1139
Practice Address - Country:US
Practice Address - Phone:814-887-5375
Practice Address - Fax:814-887-5393
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP038900L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist