Provider Demographics
NPI:1417582743
Name:VARUGHESE, SUSAN SAM
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:SAM
Last Name:VARUGHESE
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 1:1458 MARK DR
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-4828
Mailing Address - Country:US
Mailing Address - Phone:516-538-3642
Mailing Address - Fax:
Practice Address - Street 1:GEORGE MOTCHAN DETENTION CENTRE CORRECTIONAL FACILITY
Practice Address - Street 2:15-15 HAZEN STREET
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370
Practice Address - Country:US
Practice Address - Phone:347-774-7462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist