Provider Demographics
NPI:1104437813
Name:KETCHAM, MALLORY ANNE (PHARMD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANNE
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNION ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:VT
Mailing Address - Zip Code:05733-1127
Mailing Address - Country:US
Mailing Address - Phone:802-247-8050
Mailing Address - Fax:802-247-4237
Practice Address - Street 1:1 UNION ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:VT
Practice Address - Zip Code:05733-1127
Practice Address - Country:US
Practice Address - Phone:802-247-8050
Practice Address - Fax:802-247-4237
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0134411183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist