Healthcare Provider Details

I. General information

NPI: 1679618987
Provider Name (Legal Business Name): SUSAN JANE NILSEN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CALUMET AVE
DESMET SD
57231
US

IV. Provider business mailing address

103 14TH ST NE
WATERTOWN SD
57201-2818
US

V. Phone/Fax

Practice location:
  • Phone: 605-854-3861
  • Fax:
Mailing address:
  • Phone: 605-886-2830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR4739
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3599
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: