Healthcare Provider Details

I. General information

NPI: 1164960282
Provider Name (Legal Business Name): SUSANNE SHULLEETA RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 EASTRIDGE RD
HENRICO VA
23229-5740
US

IV. Provider business mailing address

2705 WILLIAMSBURG RD
RICHMOND VA
23231
US

V. Phone/Fax

Practice location:
  • Phone: 804-288-4396
  • Fax:
Mailing address:
  • Phone: 804-222-2705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202011055
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number020201105
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: