Provider Demographics
NPI:1427110543
Name:MARANDOLA-KENVIN, MARY BETH (RPH)
Entity type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:MARANDOLA-KENVIN
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 1:970 WARTER GROVE COURT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:NORTHSIDE HOSPITAL
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28R101696700183500000X
GARPH018655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist