Provider Demographics
NPI:1902274608
Name:DIETZE, SUSAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:DIETZE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1352 W 15TH ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2000
Mailing Address - Country:US
Mailing Address - Phone:850-873-6888
Mailing Address - Fax:850-873-6163
Practice Address - Street 1:1352 W 15TH ST
Practice Address - Street 2:SUITE 8
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2000
Practice Address - Country:US
Practice Address - Phone:850-873-6888
Practice Address - Fax:850-873-6163
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP449251183500000X
FLPS53751183500000X
DEA1-0004739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist