MEDICARE: MARK LUCIAN DEMMER RPH

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	14157	AZ

General Provider Information

NPI Number	:	1558742684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK LUCIAN DEMMER RPH

Provider Business Mailing Address
First Line	:	1745 MIAMI AVE
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-4020
Country	:	US
Telephone Number	:	928-542-5554
Fax Number	:

Provider Business Practice Location Address
First Line	:	1745 MIAMI AVE
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-4020
Country	:	US
Telephone Number	:	928-542-5554
Fax Number	:

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

Provider Enumeration Date	:	06/15/2015
Last Update Date	:	06/15/2015

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