Provider Demographics
NPI:1992012454
Name:JERUZAL, SUE ELLEN (DPH)
Entity Type:Individual
Prefix:DR
First Name:SUE ELLEN
Middle Name:
Last Name:JERUZAL
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 S MENDENHALL RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4244
Mailing Address - Country:US
Mailing Address - Phone:901-683-8843
Mailing Address - Fax:901-680-5621
Practice Address - Street 1:540 S MENDENHALL RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4244
Practice Address - Country:US
Practice Address - Phone:901-683-8843
Practice Address - Fax:901-680-5621
Is Sole Proprietor?:No
Enumeration Date:2010-09-04
Last Update Date:2010-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC6352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist