Provider Demographics
NPI:1710231659
Name:MIAZGA, SUSAN ELAINE (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:MIAZGA
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:N54W6135 MILL ST
Mailing Address - Street 2:STE 300
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2021
Mailing Address - Country:US
Mailing Address - Phone:262-375-0010
Mailing Address - Fax:
Practice Address - Street 1:N54W6135 MILL ST
Practice Address - Street 2:STE 300
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2021
Practice Address - Country:US
Practice Address - Phone:262-375-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9990-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist