Provider Demographics
NPI:1427525518
Name:SUSSMAN, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:SUSSMAN
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 1:36248 TURTLE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-8166
Mailing Address - Country:US
Mailing Address - Phone:406-529-0235
Mailing Address - Fax:
Practice Address - Street 1:36318 MEMORY LN
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-7265
Practice Address - Country:US
Practice Address - Phone:406-883-9221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-27
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8935183500000X
NV20032183500000X
MT71154183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist