Provider Demographics
NPI:1043431612
Name:MARSHALL, SUSAN MYRICK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MYRICK
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2457 S. 413TH RD.
Mailing Address - Street 2:
Mailing Address - City:EAST PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63845
Mailing Address - Country:US
Mailing Address - Phone:573-649-2286
Mailing Address - Fax:
Practice Address - Street 1:124 N. WASHINGTON
Practice Address - Street 2:
Practice Address - City:EAST PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63845
Practice Address - Country:US
Practice Address - Phone:573-649-3923
Practice Address - Fax:573-649-3761
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004031011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO358755809Medicaid