Provider Demographics
NPI:1316613821
Name:MALLORY, MARCUS (PHARMD)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:MALLORY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 E GREEN MEADOWS RD APT 210
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-3747
Mailing Address - Country:US
Mailing Address - Phone:573-205-6145
Mailing Address - Fax:
Practice Address - Street 1:700 N PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4373
Practice Address - Country:US
Practice Address - Phone:573-442-0194
Practice Address - Fax:573-443-8253
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021031841183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist