MEDICARE: MS. SUSAN L CERRILLO PHARM.D.

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	1835N1003X	Nutrition Support Pharmacist	PH60081366	WA
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PH60081366	WA
3	1835P1200X	Pharmacotherapy Pharmacist	PH60081366	WA

General Provider Information

NPI Number	:	1104182088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN L CERRILLO PHARM.D.

Provider Business Mailing Address
First Line	:	2012 HOXIE AVE
Second Line	:
City	:	RICHLAND
State	:	WA
Zip	:	99354-2022
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1906 GEORGE WASHINGTON WAY
Second Line	:
City	:	RICHLAND
State	:	WA
Zip	:	99354-2308
Country	:	US
Telephone Number	:	509-943-9173
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2012
Last Update Date	:	04/05/2012

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