Provider Demographics
NPI:1306409685
Name:SPICELAND, MARY SUSAN (DPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:SPICELAND
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 S RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-4739
Mailing Address - Country:US
Mailing Address - Phone:931-645-2494
Mailing Address - Fax:931-551-8294
Practice Address - Street 1:1051 S RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-4303
Practice Address - Country:US
Practice Address - Phone:931-645-2494
Practice Address - Fax:931-551-8294
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist