Provider Demographics
NPI:1750303053
Name:DAUGHTRY, SUSANNAH C
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:C
Last Name:DAUGHTRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 HEALTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-2054
Mailing Address - Country:US
Mailing Address - Phone:334-479-0541
Mailing Address - Fax:334-479-0586
Practice Address - Street 1:408 HEALTHWEST DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2054
Practice Address - Country:US
Practice Address - Phone:334-479-0541
Practice Address - Fax:334-479-0586
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist