MEDICARE: MARY SUTPHEN

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	036924	NY

General Provider Information

NPI Number	:	1972826949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY SUTPHEN

Provider Business Mailing Address
First Line	:	131 LAWRENCE ST
Second Line	:
City	:	SARATOGA SPGS
State	:	NY
Zip	:	12866-1346
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	131 LAWRENCE ST
Second Line	:
City	:	SARATOGA SPGS
State	:	NY
Zip	:	12866-1346
Country	:	US
Telephone Number	:	518-691-1461
Fax Number	:

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

Provider Enumeration Date	:	03/05/2010
Last Update Date	:	03/05/2010

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Directions to “ MARY SUTPHEN ” Practice Location

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