Provider Demographics
NPI:1790511194
Name:DIERKES, SUZANNE
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:DIERKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 BRANDING IRON RD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-8448
Mailing Address - Country:US
Mailing Address - Phone:314-560-9940
Mailing Address - Fax:
Practice Address - Street 1:200 S 23RD AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3965
Practice Address - Country:US
Practice Address - Phone:406-586-4785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT102047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist