Provider Demographics
NPI:1679860472
Name:DAVIS, SUSAN MARY (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:DAVIS
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 1:6100 PASEO DEL NORTE NE
Mailing Address - Street 2:T-2031
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1512
Mailing Address - Country:US
Mailing Address - Phone:505-346-0136
Mailing Address - Fax:505-338-3392
Practice Address - Street 1:6100 PASEO DEL NORTE NE
Practice Address - Street 2:T-2031
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1512
Practice Address - Country:US
Practice Address - Phone:505-346-0136
Practice Address - Fax:505-338-3392
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00004694183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist