Provider Demographics
NPI:1063734879
Name:SMITH, MAVIS LYNNE (RPH)
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:LYNNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-3651
Mailing Address - Country:US
Mailing Address - Phone:618-451-0521
Mailing Address - Fax:618-451-0522
Practice Address - Street 1:3100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040
Practice Address - Country:US
Practice Address - Phone:618-451-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-20
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021566183500000X
MO041315183500000X
IL051-034990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist