Provider Demographics
NPI:1275134652
Name:WAY, SUSAN LYNN
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNN
Last Name:WAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SUNNY DALE CT
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-4063
Mailing Address - Country:US
Mailing Address - Phone:618-741-7744
Mailing Address - Fax:
Practice Address - Street 1:610 WESLEY DR
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1894
Practice Address - Country:US
Practice Address - Phone:618-259-0293
Practice Address - Fax:618-259-8757
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051287184183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist