MEDICARE: SUSAN PERRY R.PH. C.PH.

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	PS40817	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS40817	OTHER	FL	PHARMACIST

General Provider Information

NPI Number	:	1841249315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN PERRY R.PH. C.PH.

Provider Business Mailing Address
First Line	:	9252 SAN JOSE BLVD
Second Line	:	STE 3304
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-9225
Country	:	US
Telephone Number	:	904-737-4664
Fax Number	:

Provider Business Practice Location Address
First Line	:	9252 SAN JOSE BLVD
Second Line	:	STE 3304
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-9225
Country	:	US
Telephone Number	:	904-737-4664
Fax Number	:

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

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	07/08/2007

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