Provider Demographics
NPI:1093316515
Name:NUTTER, SUSAN B (BS, PHARMACY)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:NUTTER
Suffix:
Gender:F
Credentials:BS, PHARMACY
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:B
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5150
Mailing Address - Fax:417-761-5151
Practice Address - Street 1:1300 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4264
Practice Address - Country:US
Practice Address - Phone:417-761-5150
Practice Address - Fax:417-761-5151
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0419951835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0000Medicaid