Provider Demographics
NPI:1962771139
Name:IVETIC, SUZANA (RPH)
Entity type:Individual
Prefix:MRS
First Name:SUZANA
Middle Name:
Last Name:IVETIC
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 1:5520 US HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-3422
Mailing Address - Country:US
Mailing Address - Phone:219-864-1476
Mailing Address - Fax:219-865-2012
Practice Address - Street 1:5520 US HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-3422
Practice Address - Country:US
Practice Address - Phone:219-864-1476
Practice Address - Fax:219-865-2012
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-17
Last Update Date:2011-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021374183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist