Provider Demographics
NPI:1306202288
Name:MOUNT, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MOUNT
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 1:1029 HIGHWAY KK
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-5065
Mailing Address - Country:US
Mailing Address - Phone:636-528-4510
Mailing Address - Fax:
Practice Address - Street 1:806 N STURGEON ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361-1426
Practice Address - Country:US
Practice Address - Phone:573-564-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO40744183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist