Provider Demographics
NPI:1477196558
Name:HARRISON, SUSSY RENEE (RPH)
Entity Type:Individual
Prefix:
First Name:SUSSY
Middle Name:RENEE
Last Name:HARRISON
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 1:271 PARK TRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:OSPREY
Mailing Address - State:FL
Mailing Address - Zip Code:34229-6801
Mailing Address - Country:US
Mailing Address - Phone:941-966-4908
Mailing Address - Fax:
Practice Address - Street 1:5598 8TH ST W
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-6341
Practice Address - Country:US
Practice Address - Phone:239-215-4144
Practice Address - Fax:239-215-4145
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist