MEDICARE: SUSAN M MALLOY PHARMD

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	S10532	AZ
2	183500000X	Pharmacist	13795	CO

General Provider Information

NPI Number	:	1972638781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M MALLOY PHARMD

Provider Business Mailing Address
First Line	:	61 S SHORTHORN DR
Second Line	:
City	:	CAMP VERDE
State	:	AZ
Zip	:	86322-7330
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	522 W FINNIE FLATS RD
Second Line	:	SUITE A
City	:	CAMP VERDE
State	:	AZ
Zip	:	86322-7265
Country	:	US
Telephone Number	:	928-567-2274
Fax Number	:

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

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/08/2007

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Directions to “ SUSAN M MALLOY PHARMD” Practice Location

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