Provider Demographics
NPI:1982819918
Name:KIDD, SUSAN MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:KIDD
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 1:14961 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-7820
Mailing Address - Country:US
Mailing Address - Phone:515-987-2172
Mailing Address - Fax:515-255-8806
Practice Address - Street 1:3330 MARTIN LUTHER KING JR PKWY
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5672
Practice Address - Country:US
Practice Address - Phone:515-255-6213
Practice Address - Fax:515-255-8806
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1614571OtherNABP
IA0233916Medicaid
IAIA17764OtherPHARMACIST LICENSE
IA0213410057Medicare ID - Type Unspecified