Provider Demographics
NPI:1215586110
Name:KOONTZ, SUSAN VIRGINIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:VIRGINIA
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 SW SIERRA CT
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-2772
Mailing Address - Country:US
Mailing Address - Phone:352-494-9291
Mailing Address - Fax:
Practice Address - Street 1:152 SW SIERRA CT
Practice Address - Street 2:
Practice Address - City:FORT WHITE
Practice Address - State:FL
Practice Address - Zip Code:32038-2772
Practice Address - Country:US
Practice Address - Phone:352-494-9291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist