MEDICARE: SUSAN FAGOT RP

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	183500000X	Pharmacist	8237	NE

General Provider Information

NPI Number	:	1154441913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN FAGOT RP

Provider Business Mailing Address
First Line	:	43431 ROAD 750
Second Line	:
City	:	LEXINGTON
State	:	NE
Zip	:	68850-5602
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	603 N WASHINGTON ST
Second Line	:
City	:	LEXINGTON
State	:	NE
Zip	:	68850-1915
Country	:	US
Telephone Number	:	308-324-6325
Fax Number	:

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

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	07/08/2007

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