MEDICARE: DOLORES SUDDS PHARMACIST

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	09185	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09185	OTHER	NV	PHARMACIST LICENSE NUMBER

General Provider Information

NPI Number	:	1700480647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOLORES SUDDS PHARMACIST

Provider Business Mailing Address
First Line	:	1910 E SERENE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-3218
Country	:	US
Telephone Number	:	702-614-3387
Fax Number	:

Provider Business Practice Location Address
First Line	:	1910 E SERENE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-3218
Country	:	US
Telephone Number	:	702-614-3387
Fax Number	:

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

Provider Enumeration Date	:	11/22/2020
Last Update Date	:	11/22/2020

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