Healthcare Provider Details

I. General information

NPI: 1275505273
Provider Name (Legal Business Name): SUE AMY MARK RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11012 19TH AVE SE
EVERETT WA
98208-5155
US

IV. Provider business mailing address

5029 125TH PL SW
MUKILTEO WA
98275-5528
US

V. Phone/Fax

Practice location:
  • Phone: 425-337-7197
  • Fax:
Mailing address:
  • Phone: 425-355-6098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00013705
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: