Healthcare Provider Details

I. General information

NPI: 1154441913
Provider Name (Legal Business Name): SUSAN FAGOT RP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 N WASHINGTON ST
LEXINGTON NE
68850-1915
US

IV. Provider business mailing address

43431 ROAD 750
LEXINGTON NE
68850-5602
US

V. Phone/Fax

Practice location:
  • Phone: 308-324-6325
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8237
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: