Provider Demographics
NPI:1407325681
Name:IACOVELLI, SUZANNE LYNN
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LYNN
Last Name:IACOVELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7830 WORMANS MILL RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7830 WORMANS MILL RD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-3034
Practice Address - Country:US
Practice Address - Phone:240-575-7345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-18
Last Update Date:2018-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060383183500000X
MD21688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5555555555555OtherN/A
MD1578854139OtherWEGMANS PHARMACY