Provider Demographics
NPI:1750810867
Name:NAM, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NAM
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 1:2240 FAIR PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1910
Mailing Address - Country:US
Mailing Address - Phone:323-254-7346
Mailing Address - Fax:323-254-3760
Practice Address - Street 1:2240 FAIR PARK AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1910
Practice Address - Country:US
Practice Address - Phone:323-254-7346
Practice Address - Fax:323-254-3760
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist