Provider Demographics
NPI:1114642634
Name:TUCKER, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TUCKER
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 1:124 PINETREE CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:AL
Mailing Address - Zip Code:35051-9333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 OLLIE AVE
Practice Address - Street 2:
Practice Address - City:CLANTON
Practice Address - State:AL
Practice Address - Zip Code:35045-2238
Practice Address - Country:US
Practice Address - Phone:205-755-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician