Healthcare Provider Details

I. General information

NPI: 1063921070
Provider Name (Legal Business Name): SUSAN A NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BELMONT ST
BROCKTON MA
02301-5596
US

IV. Provider business mailing address

3 6TH AVE
HALIFAX MA
02338-1316
US

V. Phone/Fax

Practice location:
  • Phone: 774-826-2185
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number22450
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number22450
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: