Provider Demographics
NPI:1063799930
Name:DEWET, SUSANNE LUCILLE
Entity type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:LUCILLE
Last Name:DEWET
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 1:979 EAST THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403
Mailing Address - Country:US
Mailing Address - Phone:423-778-6336
Mailing Address - Fax:423-778-3054
Practice Address - Street 1:979 EAST THIRD STREET
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403
Practice Address - Country:US
Practice Address - Phone:423-778-6336
Practice Address - Fax:423-778-3054
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-07
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26458183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist