Provider Demographics
NPI:1053861724
Name:DANIELL, SUSAN MARY (PHARMD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:DANIELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-6700
Mailing Address - Country:US
Mailing Address - Phone:815-351-6414
Mailing Address - Fax:
Practice Address - Street 1:701 KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4103
Practice Address - Country:US
Practice Address - Phone:775-747-1628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051290128183500000X
NV19313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
200926OtherNABP