Provider Demographics
NPI:1629363478
Name:PAINE, SUSAN M (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:PAINE
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 1:3535 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5334
Mailing Address - Country:US
Mailing Address - Phone:715-392-9876
Mailing Address - Fax:
Practice Address - Street 1:3535 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5334
Practice Address - Country:US
Practice Address - Phone:715-392-9876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11538-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist