Provider Demographics
NPI:1063706273
Name:ZOFCHAK, SUSAN (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ZOFCHAK
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 1:178 W ELLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1408
Mailing Address - Country:US
Mailing Address - Phone:503-623-8334
Mailing Address - Fax:503-623-7077
Practice Address - Street 1:178 W ELLENDALE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1408
Practice Address - Country:US
Practice Address - Phone:503-623-8334
Practice Address - Fax:503-623-7077
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist