Provider Demographics
NPI:1437481835
Name:ETZ, MARY ANNE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:ETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:B
Other - Last Name:ETZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:14 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-2102
Mailing Address - Country:US
Mailing Address - Phone:607-753-1591
Mailing Address - Fax:607-753-0570
Practice Address - Street 1:14 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2102
Practice Address - Country:US
Practice Address - Phone:607-753-1591
Practice Address - Fax:607-753-0570
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist