=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205106283
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. SUSAN MARJORIE SKOLLY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2012
-----------------------------------------------------
Last Update Date | 03/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5050 COUNTY ROAD 472
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34484-3750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-689-6424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 899 BRIGHTWATER CIR
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-4222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-352-4644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS19844
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 51-33333
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------