Provider Demographics
NPI:1922476076
Name:DATKULIAK, SUELLEN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUELLEN
Middle Name:
Last Name:DATKULIAK
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 1:1867 COUNTY ROAD 655
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-9384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1867 COUNTY ROAD 655
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-9384
Practice Address - Country:US
Practice Address - Phone:419-368-9244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-07
Last Update Date:2015-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist