1790860088 NPI number — SUSONG-SYDNOR INC

Table of content: (NPI 1790860088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790860088 NPI number — SUSONG-SYDNOR INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUSONG-SYDNOR INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HOWARDS PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790860088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1305 TUSCULUM BLVD # B
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
GREENEVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37745-4160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-639-5134
Provider Business Mailing Address Fax Number:
423-639-5134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 TUSCULUM BLVD # B
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
GREENEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37745-4160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-639-5134
Provider Business Practice Location Address Fax Number:
423-639-5134
Provider Enumeration Date:
10/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SUSONG
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
423-639-8631

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2195 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4426121 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9449650 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".