Provider Demographics
NPI:1053734293
Name:GRAVES, SUSAN PAGE (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:PAGE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3146 LAKE RANCH CIR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-1014
Mailing Address - Country:US
Mailing Address - Phone:770-714-3496
Mailing Address - Fax:
Practice Address - Street 1:3146 LAKE RANCH CIR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-1014
Practice Address - Country:US
Practice Address - Phone:770-714-3496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist