Provider Demographics
NPI:1619215076
Name:CUSACK, MARIE MARGARETE (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:MARGARETE
Last Name:CUSACK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 OCEAN SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-3620
Mailing Address - Country:US
Mailing Address - Phone:386-441-3730
Mailing Address - Fax:386-441-3774
Practice Address - Street 1:1258 OCEAN SHORE BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-3620
Practice Address - Country:US
Practice Address - Phone:386-441-3730
Practice Address - Fax:386-441-3774
Is Sole Proprietor?:No
Enumeration Date:2013-01-19
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37735183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist