Provider Demographics
NPI:1679618987
Name:NILSEN, SUSAN JANE (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:NILSEN
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 1:103 14TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-2818
Mailing Address - Country:US
Mailing Address - Phone:605-886-2830
Mailing Address - Fax:
Practice Address - Street 1:201 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:DESMET
Practice Address - State:SD
Practice Address - Zip Code:57231
Practice Address - Country:US
Practice Address - Phone:605-854-3861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR4739183500000X
ND3599183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist