Provider Demographics
NPI:1588914360
Name:TATA, SUSHAMA DAYAL
Entity type:Individual
Prefix:MRS
First Name:SUSHAMA
Middle Name:DAYAL
Last Name:TATA
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 1:1105 S MAIN ST
Mailing Address - Street 2:03832
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7478
Mailing Address - Country:US
Mailing Address - Phone:512-821-9321
Mailing Address - Fax:
Practice Address - Street 1:1105 S MAIN ST
Practice Address - Street 2:03832
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7478
Practice Address - Country:US
Practice Address - Phone:512-821-9321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist