Provider Demographics
NPI:1174828479
Name:BASS, SUE MAXEY
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:MAXEY
Last Name:BASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:MAXEY
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:2840 LINKHORNE DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-3322
Mailing Address - Country:US
Mailing Address - Phone:434-384-2670
Mailing Address - Fax:
Practice Address - Street 1:2840 LINKHORNE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-3322
Practice Address - Country:US
Practice Address - Phone:434-384-2670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202005070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist