Provider Demographics
NPI:1063750602
Name:KANE, SUSAN M (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:KANE
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 1:670 MARSH LANDING PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5850
Mailing Address - Country:US
Mailing Address - Phone:904-273-7606
Mailing Address - Fax:904-273-7612
Practice Address - Street 1:670 MARSH LANDING PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-5850
Practice Address - Country:US
Practice Address - Phone:904-273-7606
Practice Address - Fax:904-273-7612
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist