Provider Demographics
NPI:1962008052
Name:SUTJITA, OSSY
Entity Type:Individual
Prefix:
First Name:OSSY
Middle Name:
Last Name:SUTJITA
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 1:7701 W SAINT JOHN RD APT 2078
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8632
Mailing Address - Country:US
Mailing Address - Phone:951-231-8202
Mailing Address - Fax:
Practice Address - Street 1:1616 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7602
Practice Address - Country:US
Practice Address - Phone:022-638-3076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist