Provider Demographics
NPI:1609491836
Name:SEVERANCE, MARTHA ELAINE (RPH)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:ELAINE
Last Name:SEVERANCE
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 1:1103 G AVE
Mailing Address - Street 2:
Mailing Address - City:GRUNDY CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:50638-1032
Mailing Address - Country:US
Mailing Address - Phone:319-824-6059
Mailing Address - Fax:
Practice Address - Street 1:2700 4TH ST SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-4351
Practice Address - Country:US
Practice Address - Phone:319-352-2735
Practice Address - Fax:319-352-4570
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist