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General NPI Number Information
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NPI Number | 1487523239
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Entity Type | Individual
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Provider Name | MIRA SUSENO PHARMD
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Gender | Female
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Dates
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Enumeration Date | 10/31/2025
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Last Update Date | 10/31/2025
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Provider Practice Location Address
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Address Line | 2650 RIDGE AVE
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City | EVANSTON
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State | IL
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Zip | 60201-1700
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Country | US
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Telephone | 847-570-1021
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Fax |
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Provider Business Mailing Address
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Address Line | 1014 HIGHLAND GROVE CT N
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City | BUFFALO GROVE
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State | IL
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Zip | 60089-7021
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Country | US
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Telephone | 847-570-1021
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835I0206X
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Taxonomy Name | Infectious Diseases Pharmacist
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License Number | 051040649
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License Number State | IL
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