Provider Demographics
NPI:1174778849
Name:WHEATLEY, MARY KATHERINE
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERINE
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:WHEATLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:728 SW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2626
Mailing Address - Country:US
Mailing Address - Phone:541-889-3390
Mailing Address - Fax:541-889-4488
Practice Address - Street 1:728 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2626
Practice Address - Country:US
Practice Address - Phone:541-889-3390
Practice Address - Fax:541-889-4488
Is Sole Proprietor?:No
Enumeration Date:2008-11-22
Last Update Date:2008-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3857183500000X
OR6366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist