Provider Demographics
NPI:1790860088
Name:SUSONG-SYDNOR INC
Entity Type:Organization
Organization Name:SUSONG-SYDNOR INC
Other - Org Name:HOWARDS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:423-639-8631
Mailing Address - Street 1:1305 TUSCULUM BLVD # B
Mailing Address - Street 2:STE 2
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4160
Mailing Address - Country:US
Mailing Address - Phone:423-639-5134
Mailing Address - Fax:423-639-5134
Practice Address - Street 1:1305 TUSCULUM BLVD # B
Practice Address - Street 2:STE 2
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4160
Practice Address - Country:US
Practice Address - Phone:423-639-5134
Practice Address - Fax:423-639-5134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN21953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4426121OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TN9449650Medicaid