Provider Demographics
NPI:1235452004
Name:SUSSDORFF, MINDY KATE (RPH)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:KATE
Last Name:SUSSDORFF
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 1:3 LEONARD AVE
Mailing Address - Street 2:APT. A
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2511
Mailing Address - Country:US
Mailing Address - Phone:518-561-4231
Mailing Address - Fax:
Practice Address - Street 1:25 CONSUMER SQARE
Practice Address - Street 2:WALMART
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-561-0685
Practice Address - Fax:518-563-3675
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist