Provider Demographics
NPI:1629364930
Name:BERECK, SUSAN MILLER (RPH)
Entity Type:Individual
Prefix:MR
First Name:SUSAN
Middle Name:MILLER
Last Name:BERECK
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 1:18415 MAY COURT
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023
Mailing Address - Country:US
Mailing Address - Phone:440-708-0082
Mailing Address - Fax:
Practice Address - Street 1:18855 N MARKET PLACE DR
Practice Address - Street 2:#2161
Practice Address - City:AURORA
Practice Address - State:OH
Practice Address - Zip Code:44202-8784
Practice Address - Country:US
Practice Address - Phone:330-562-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist