Provider Demographics
NPI:1922515691
Name:KELLUM, SUSAN (PHARM D)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KELLUM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 503
Mailing Address - Street 2:
Mailing Address - City:COMER
Mailing Address - State:GA
Mailing Address - Zip Code:30629-0503
Mailing Address - Country:US
Mailing Address - Phone:706-340-7894
Mailing Address - Fax:
Practice Address - Street 1:26 FRANKLIN SPRINGS ST
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-4109
Practice Address - Country:US
Practice Address - Phone:706-340-7894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist