Healthcare Provider Details

I. General information

NPI: 1568231777
Provider Name (Legal Business Name): JESUS JOHN SUSI RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN SUSI

II. Dates (important events)

Enumeration Date: 12/28/2023
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18110 SE 34TH ST
VANCOUVER WA
98683-9418
US

IV. Provider business mailing address

5000 NE 42ND ST
VANCOUVER WA
98661-4290
US

V. Phone/Fax

Practice location:
  • Phone: 800-330-3665
  • Fax:
Mailing address:
  • Phone: 503-935-6740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH61468281
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: