Provider Demographics
NPI:1275505273
Name:MARK, SUE AMY (RPH)
Entity Type:Individual
Prefix:
First Name:SUE AMY
Middle Name:
Last Name:MARK
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 1:5029 125TH PL SW
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-5528
Mailing Address - Country:US
Mailing Address - Phone:425-355-6098
Mailing Address - Fax:
Practice Address - Street 1:11012 19TH AVE SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5155
Practice Address - Country:US
Practice Address - Phone:425-337-7197
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00013705183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist