Provider Demographics
NPI:1043644230
Name:WIDUP, SUSAN (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WIDUP
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 NORTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-6748
Mailing Address - Country:US
Mailing Address - Phone:574-266-5582
Mailing Address - Fax:574-266-7887
Practice Address - Street 1:3101 NORTHVIEW DR
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-6748
Practice Address - Country:US
Practice Address - Phone:574-266-5582
Practice Address - Fax:574-266-7887
Is Sole Proprietor?:No
Enumeration Date:2013-08-25
Last Update Date:2013-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015183A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist