Provider Demographics
NPI:1285771774
Name:FREESE, SUSAN C (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:FREESE
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:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631-0189
Mailing Address - Country:US
Mailing Address - Phone:360-642-3133
Mailing Address - Fax:360-642-5133
Practice Address - Street 1:101 1ST AVE S
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-0167
Practice Address - Country:US
Practice Address - Phone:360-642-3133
Practice Address - Fax:360-642-5133
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH00010369OtherPHARMACIST