Provider Demographics
NPI:1992280770
Name:SUSAK, CHADLYN RENAE (PHARMD)
Entity type:Individual
Prefix:
First Name:CHADLYN
Middle Name:RENAE
Last Name:SUSAK
Suffix:
Gender:F
Credentials:PHARMD
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 1253
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-1903
Mailing Address - Country:US
Mailing Address - Phone:360-581-4713
Mailing Address - Fax:
Practice Address - Street 1:201 S WATER ST
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3675
Practice Address - Country:US
Practice Address - Phone:509-962-0533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60868656183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH60868656OtherPHARMACIST LICENSE