Provider Demographics
NPI:1114023496
Name:ZIMMERMAN, MARY HAZEN I (RPH, BCPS, CACP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:HAZEN
Last Name:ZIMMERMAN
Suffix:I
Gender:F
Credentials:RPH, BCPS, CACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4307 ODANA RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1511
Mailing Address - Country:US
Mailing Address - Phone:608-256-1901
Mailing Address - Fax:608-280-7024
Practice Address - Street 1:4307 ODANA RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1511
Practice Address - Country:US
Practice Address - Phone:608-256-1901
Practice Address - Fax:608-280-7024
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8968-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist