Healthcare Provider Details

I. General information

NPI: 1336786102
Provider Name (Legal Business Name): SUSAN JARACZ RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2019
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 PINE LAKE AVE
LA PORTE IN
46350-3027
US

IV. Provider business mailing address

5222 N CAMERON
LA PORTE IN
46350-7600
US

V. Phone/Fax

Practice location:
  • Phone: 219-325-3152
  • Fax: 219-325-3251
Mailing address:
  • Phone: 219-873-7194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26018309A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: