Healthcare Provider Details

I. General information

NPI: 1356944250
Provider Name (Legal Business Name): BRANDON SUSA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2020
Last Update Date: 11/21/2020
Certification Date: 11/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1308
US

IV. Provider business mailing address

1922 CLEOPATRA CT NE
ALBUQUERQUE NM
87112-3504
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-5210
  • Fax:
Mailing address:
  • Phone: 312-998-6703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00009394
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: