Provider Demographics
NPI:1467041731
Name:DAVIS, SUSAN (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DAVIS
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 1:2 UPPER MDW
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06035-2937
Mailing Address - Country:US
Mailing Address - Phone:860-402-8230
Mailing Address - Fax:
Practice Address - Street 1:42 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:VERNON ROCKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06066-6606
Practice Address - Country:US
Practice Address - Phone:860-875-9263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT8761183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist