MEDICARE: MARK R SUITOR R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302030501	MI

General Provider Information

NPI Number	:	1386910446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK R SUITOR R.PH.

Provider Business Mailing Address
First Line	:	8911 LAKE LEELANAU DR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7776
Country	:	US
Telephone Number	:	231-463-6671
Fax Number	:

Provider Business Practice Location Address
First Line	:	4144 US HIGHWAY 31 S
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49685-9228
Country	:	US
Telephone Number	:	231-943-4017
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2012
Last Update Date	:	03/22/2012

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