Healthcare Provider Details

I. General information

NPI: 1205106283
Provider Name (Legal Business Name): DR. SUSAN MARJORIE SKOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN SANDBECK PHARMD, MS

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 COUNTY ROAD 472
OXFORD FL
34484-3750
US

IV. Provider business mailing address

899 BRIGHTWATER CIR
MAITLAND FL
32751-4222
US

V. Phone/Fax

Practice location:
  • Phone: 352-689-6424
  • Fax:
Mailing address:
  • Phone: 561-352-4644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS19844
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number51-33333
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: