Provider Demographics
NPI:1417398801
Name:ADAMS, MARY SUE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUE
Last Name:ADAMS
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 1:2616 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-5102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2616 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-5102
Practice Address - Country:US
Practice Address - Phone:850-265-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-13
Last Update Date:2013-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10484183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician