Provider Demographics
NPI:1134301708
Name:SUTTER, SUSAN LORRAINE (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LORRAINE
Last Name:SUTTER
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 1:705 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3053
Mailing Address - Country:US
Mailing Address - Phone:920-356-0040
Mailing Address - Fax:920-356-0056
Practice Address - Street 1:705 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3053
Practice Address - Country:US
Practice Address - Phone:920-356-0040
Practice Address - Fax:920-356-0056
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist