Provider Demographics
NPI:1467585679
Name:MUKATIS, SUSAN CORREA (RPH)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CORREA
Last Name:MUKATIS
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 1:2851 NW MONTEREY PL
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3435
Mailing Address - Country:US
Mailing Address - Phone:541-758-2658
Mailing Address - Fax:541-768-6585
Practice Address - Street 1:3517 NW SAMARITAN DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3767
Practice Address - Country:US
Practice Address - Phone:541-768-5185
Practice Address - Fax:541-768-6585
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7699183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist