=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881162535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSET IGLESIAS RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2018
-----------------------------------------------------
Last Update Date | 11/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5473 NW SAINT JAMES DR
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-3444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-878-6119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1778 PIERSIDE CIR
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-8035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-400-0494
-----------------------------------------------------
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 | PS58315
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------