Provider Demographics
NPI:1861571564
Name:PENNELL, SUSAN M (RPH CCN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:PENNELL
Suffix:
Gender:F
Credentials:RPH CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2262 N MCKINLEY RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9420
Mailing Address - Country:US
Mailing Address - Phone:810-487-0503
Mailing Address - Fax:
Practice Address - Street 1:G3320 BEECHER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3614
Practice Address - Country:US
Practice Address - Phone:810-732-8720
Practice Address - Fax:810-732-6267
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0237891835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support