Provider Demographics
NPI:1225448137
Name:WAGENSCHUTZ, SUSAN (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WAGENSCHUTZ
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 1:320 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-1056
Mailing Address - Country:US
Mailing Address - Phone:810-300-0957
Mailing Address - Fax:
Practice Address - Street 1:4775 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3405
Practice Address - Country:US
Practice Address - Phone:810-385-2164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020245621835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy