Provider Demographics
NPI:1154441913
Name:FAGOT, SUSAN (RP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FAGOT
Suffix:
Gender:F
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43431 ROAD 750
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68850-5602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:603 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NE
Practice Address - Zip Code:68850-1915
Practice Address - Country:US
Practice Address - Phone:308-324-6325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist