Provider Demographics
NPI:1871539692
Name:STALLWORTH, MARY M (RPH)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:3417 CLUB HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36605-3931
Mailing Address - Country:US
Mailing Address - Phone:251-476-7744
Mailing Address - Fax:
Practice Address - Street 1:1970 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-2924
Practice Address - Country:US
Practice Address - Phone:251-666-6988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist