Provider Demographics
NPI:1962726513
Name:DE GUZMAN, MARIE GRACE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:GRACE
Last Name:DE GUZMAN
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 1:10 WILLOWBROOK CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-6200
Mailing Address - Country:US
Mailing Address - Phone:906-776-1085
Mailing Address - Fax:
Practice Address - Street 1:1810 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3615
Practice Address - Country:US
Practice Address - Phone:906-779-2163
Practice Address - Fax:906-779-0012
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034304183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist