Provider Demographics
NPI:1154751873
Name:HACKNEY, SUSAN (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HACKNEY
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 1:14284 BRIARFIELD LN
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9791
Mailing Address - Country:US
Mailing Address - Phone:616-843-7354
Mailing Address - Fax:
Practice Address - Street 1:15000 US 31
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-8881
Practice Address - Country:US
Practice Address - Phone:616-847-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI53020296661835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist