Provider Demographics
NPI:1205106283
Name:SKOLLY, SUSAN MARJORIE
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARJORIE
Last Name:SKOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:SANDBECK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD, MS
Mailing Address - Street 1:899 BRIGHTWATER CIR
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4222
Mailing Address - Country:US
Mailing Address - Phone:561-352-4644
Mailing Address - Fax:
Practice Address - Street 1:5050 COUNTY ROAD 472
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:FL
Practice Address - Zip Code:34484-3750
Practice Address - Country:US
Practice Address - Phone:352-689-6424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19844183500000X
IL51-33333183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist