Provider Demographics
NPI:1104979459
Name:BATES, MARY S (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:BATES
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 1:4095 MOUNT CARMEL CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-5183
Mailing Address - Country:US
Mailing Address - Phone:770-207-9036
Mailing Address - Fax:
Practice Address - Street 1:17 MONROE HWY
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-7186
Practice Address - Country:US
Practice Address - Phone:770-307-2906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH010198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist