Provider Demographics
NPI:1366060188
Name:HARRIS, MARY B
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:HARRIS
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 1:8009 GOODMAN DR
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-7318
Mailing Address - Country:US
Mailing Address - Phone:515-276-0762
Mailing Address - Fax:515-252-9997
Practice Address - Street 1:5440 NW 86TH ST
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1737
Practice Address - Country:US
Practice Address - Phone:515-331-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14968183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist