Provider Demographics
NPI:1871935718
Name:WIMMER, SUSAN MAE
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MAE
Last Name:WIMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:MAE
Other - Last Name:WIMMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1606 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-2706
Mailing Address - Country:US
Mailing Address - Phone:812-238-4935
Mailing Address - Fax:812-238-7946
Practice Address - Street 1:1606 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2706
Practice Address - Country:US
Practice Address - Phone:812-238-4935
Practice Address - Fax:812-238-7646
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016432A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist