MEDICARE: SUSAN KLEMENTOVICH 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	2957	NH
2	183500000X	Pharmacist	PR4566	ME

General Provider Information

NPI Number	:	1881912863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KLEMENTOVICH RPH

Provider Business Mailing Address
First Line	:	PO BOX 1802
Second Line	:	1623 WHITE MTN HGWY
City	:	NORTH CONWAY
State	:	NH
Zip	:	03860-1802
Country	:	US
Telephone Number	:	603-356-5512
Fax Number	:

Provider Business Practice Location Address
First Line	:	1623 WHITE MOUNTAIN HWY
Second Line	:
City	:	NORTH CONWAY
State	:	NH
Zip	:	03860-5157
Country	:	US
Telephone Number	:	603-356-5512
Fax Number	:

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

Provider Enumeration Date	:	05/14/2010
Last Update Date	:	05/14/2010

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