Provider Demographics
NPI:1023439452
Name:SIEBEN, MARY (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SIEBEN
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 1:946 DEERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LAINGSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48848-8603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12821 CROSSOVER DR
Practice Address - Street 2:MEIJER PHARMACY 209
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820
Practice Address - Country:US
Practice Address - Phone:517-669-4610
Practice Address - Fax:517-669-4765
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist