Provider Demographics
NPI:1841764503
Name:FAIRCLOTH, SUSANNE INMAN (RPH)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:INMAN
Last Name:FAIRCLOTH
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:PO BOX 2760
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-2760
Mailing Address - Country:US
Mailing Address - Phone:910-522-1041
Mailing Address - Fax:910-522-1085
Practice Address - Street 1:812 CANDY PARK RD STE 7101
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-9129
Practice Address - Country:US
Practice Address - Phone:910-522-1041
Practice Address - Fax:910-522-1085
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist