Provider Demographics
NPI:1992817506
Name:WYNN, SUE ELLEN (RPH)
Entity type:Individual
Prefix:MS
First Name:SUE
Middle Name:ELLEN
Last Name:WYNN
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 517
Mailing Address - Street 2:
Mailing Address - City:WHITLEY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42653-0517
Mailing Address - Country:US
Mailing Address - Phone:606-376-7171
Mailing Address - Fax:606-376-7178
Practice Address - Street 1:1755 NORTH HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-0517
Practice Address - Country:US
Practice Address - Phone:606-376-7171
Practice Address - Fax:606-376-7178
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8033183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist