MEDICARE: SUZANNE COOLEY PHARMACY TECHNICIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

General Provider Information

NPI Number	:	1710252655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE COOLEY PHARMACY TECHNICIAN

Provider Business Mailing Address
First Line	:	6108 CHENNAULT BEACH DR
Second Line	:
City	:	MUKILTEO
State	:	WA
Zip	:	98275-4664
Country	:	US
Telephone Number	:	317-902-9704
Fax Number	:

Provider Business Practice Location Address
First Line	:	6108 CHENNAULT BEACH DR
Second Line	:
City	:	MUKILTEO
State	:	WA
Zip	:	98275-4664
Country	:	US
Telephone Number	:	317-902-9704
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2012
Last Update Date	:	03/10/2012

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