Provider Demographics
NPI:1558742684
Name:DEMMER, MARK LUCIAN (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LUCIAN
Last Name:DEMMER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 MIAMI AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4020
Mailing Address - Country:US
Mailing Address - Phone:928-542-5554
Mailing Address - Fax:
Practice Address - Street 1:1745 MIAMI AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4020
Practice Address - Country:US
Practice Address - Phone:928-542-5554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist