Provider Demographics
NPI:1669825691
Name:MAXWELL, SUSANNE LANE (RPH)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:LANE
Last Name:MAXWELL
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 1:22 S ZETTEROWER AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4866
Mailing Address - Country:US
Mailing Address - Phone:912-764-6454
Mailing Address - Fax:912-489-1110
Practice Address - Street 1:22 S ZETTEROWER AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4866
Practice Address - Country:US
Practice Address - Phone:912-764-6454
Practice Address - Fax:912-489-1110
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH16900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist