Provider Demographics
NPI:1619427036
Name:BURCHETT, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BURCHETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-8697
Mailing Address - Country:US
Mailing Address - Phone:740-259-8079
Mailing Address - Fax:
Practice Address - Street 1:63 SCENIC DR
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-8697
Practice Address - Country:US
Practice Address - Phone:740-259-8079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist