Provider Demographics
NPI:1063921070
Name:NELSON, SUSAN A
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:NELSON
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 1:3 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:MA
Mailing Address - Zip Code:02338-1316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:774-826-2185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224501835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist