Provider Demographics
NPI:1063786226
Name:LOTT, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33901 MARIANA DR APT 8
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2447
Mailing Address - Country:US
Mailing Address - Phone:949-661-7241
Mailing Address - Fax:
Practice Address - Street 1:33961 DOHENY PARK RD
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-4835
Practice Address - Country:US
Practice Address - Phone:949-240-9573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH39844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist