Provider Demographics
NPI:1134409360
Name:SUSKO, LESLIE R (RPH)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:R
Last Name:SUSKO
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 1:1150 REVOLUTION MILL DR STE 3
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5086
Mailing Address - Country:US
Mailing Address - Phone:336-285-7985
Mailing Address - Fax:
Practice Address - Street 1:1150 REVOLUTION MILL DR STE 3
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405
Practice Address - Country:US
Practice Address - Phone:336-285-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist