Provider Demographics
NPI:1467650408
Name:GROOM, SUSAN L (PHARMD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:GROOM
Suffix:
Gender:F
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:RR 2 BOX 46
Mailing Address - Street 2:
Mailing Address - City:GRANT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64456-8948
Mailing Address - Country:US
Mailing Address - Phone:660-326-2183
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 46
Practice Address - Street 2:
Practice Address - City:GRANT CITY
Practice Address - State:MO
Practice Address - Zip Code:64456-8948
Practice Address - Country:US
Practice Address - Phone:660-326-2183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000164251183500000X
MO171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2000164251OtherBOARD OF PHARMACY