Provider Demographics
NPI:1992822415
Name:MARTIN, SUSAN MARIE (RPH)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:MARTIN
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 1:1222 E DOVER CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-1943
Mailing Address - Country:US
Mailing Address - Phone:563-210-1600
Mailing Address - Fax:
Practice Address - Street 1:2200 W KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5300
Practice Address - Country:US
Practice Address - Phone:563-391-1543
Practice Address - Fax:563-391-9117
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist