Provider Demographics
NPI:1619425162
Name:PHONG, SUZANNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:PHONG
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 1:12505 E. 16TH AVE
Mailing Address - Street 2:F757
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045
Mailing Address - Country:US
Mailing Address - Phone:720-846-5342
Mailing Address - Fax:
Practice Address - Street 1:12605 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2545
Practice Address - Country:US
Practice Address - Phone:626-641-6619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA0021497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist