Provider Demographics
NPI:1437616661
Name:SUSA, RONALD (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:
Last Name:SUSA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TRAVIS BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3804
Mailing Address - Country:US
Mailing Address - Phone:707-422-3460
Mailing Address - Fax:
Practice Address - Street 1:300 TRAVIS BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3804
Practice Address - Country:US
Practice Address - Phone:707-422-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-24
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist