Provider Demographics
NPI:1164960282
Name:SHULLEETA, SUSANNE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:
Last Name:SHULLEETA
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 1:2705 WILLIAMSBURG RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231
Mailing Address - Country:US
Mailing Address - Phone:804-222-2705
Mailing Address - Fax:
Practice Address - Street 1:2708 WILLIAMSBURG RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231
Practice Address - Country:US
Practice Address - Phone:804-222-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist