=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306202288
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MOUNT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2016
-----------------------------------------------------
Last Update Date | 01/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 806 N STURGEON ST
-----------------------------------------------------
City | MONTGOMERY CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63361-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-564-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1029 HIGHWAY KK
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63379-5065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-528-4510
-----------------------------------------------------
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 | 40744
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------