Healthcare Provider Details

I. General information

NPI: 1447986419
Provider Name (Legal Business Name): SUSAN WOODLIEF SHUPE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COUNTY SERVICES PKWY SW
MARIETTA GA
30008-4010
US

IV. Provider business mailing address

1650 COUNTY SERVICES PKWY SW
MARIETTA GA
30008-4010
US

V. Phone/Fax

Practice location:
  • Phone: 770-514-2345
  • Fax: 770-514-2393
Mailing address:
  • Phone: 770-514-2345
  • Fax: 770-514-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number012659
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: