1134309339 NPI number — MS. SUSAN L DEVERNA RPH.

Table of content: MS. SUSAN L DEVERNA RPH. (NPI 1134309339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134309339 NPI number — MS. SUSAN L DEVERNA RPH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEVERNA
Provider First Name:
SUSAN
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RPH.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1134309339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3341 MOUNTAIN HILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKE FOREST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27587-9752
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-297-0293
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3341 MOUNTAIN HILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAKE FOREST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27587-9752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-297-0293
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  041675 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 25379 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01117995 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com