MEDICARE: SUSONG PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	177	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4415495	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073698361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSONG PHARMACY INC

Provider Business Mailing Address
First Line	:	2255 E ANDREW JOHNSON HWY
Second Line	:	SUITE 2
City	:	GREENEVILLE
State	:	TN
Zip	:	37745-4375
Country	:	US
Telephone Number	:	423-639-8631
Fax Number	:	423-639-0302

Provider Business Practice Location Address
First Line	:	2255 E ANDREW JOHNSON HWY
Second Line	:
City	:	GREENEVILLE
State	:	TN
Zip	:	37745-4375
Country	:	US
Telephone Number	:	423-639-8631
Fax Number	:	423-639-0302

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES SUSONG
Credential	:	PHRM D
Telephone Number	:	423-639-8631

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	02/15/2012

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Directions to “SUSONG PHARMACY INC ” Practice Location

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