=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750435822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCILLE MARY SUFFERN B.S, CPHT, CPT1
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 06/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38256 MEMBERS CLUB DR
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92563-5859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-420-4326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38256 MEMBERS CLUB DR
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92563-5859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-420-4326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | TCH16544
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------