Provider Demographics
NPI:1720368707
Name:AYCOCK, SUSAN (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:AYCOCK
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 1:817 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:LA
Mailing Address - Zip Code:71040-3322
Mailing Address - Country:US
Mailing Address - Phone:318-927-3537
Mailing Address - Fax:318-927-6400
Practice Address - Street 1:817 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:LA
Practice Address - Zip Code:71040-3322
Practice Address - Country:US
Practice Address - Phone:318-927-3537
Practice Address - Fax:318-927-6400
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13783OtherPHARMACY LISENCE