Basic Information
Provider Information
NPI: 1033556816
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PRESTON
FirstName: SUSAN
MiddleName: C
NamePrefix:  
NameSuffix:  
Credential: RPH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 2557
Address2:  
City: DOUGLAS
State: GA
PostalCode: 315342557
CountryCode: US
TelephoneNumber: 9123841898
FaxNumber: 9123837109
Practice Location
Address1: 250 PETERSON AVE S
Address2:  
City: DOUGLAS
State: GA
PostalCode: 315335237
CountryCode: US
TelephoneNumber: 9123841898
FaxNumber: 9123837109
Other Information
ProviderEnumerationDate: 06/03/2013
LastUpdateDate: 06/03/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000XRPH017755GAY Pharmacy Service ProvidersPharmacist 

No ID Information.


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