Provider Demographics
NPI:1518562586
Name:TSAGRIS, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:TSAGRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 KINCRAIG DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-9299
Mailing Address - Country:US
Mailing Address - Phone:219-617-4483
Mailing Address - Fax:
Practice Address - Street 1:3240 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5055
Practice Address - Country:US
Practice Address - Phone:219-762-3998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019263A1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Single Specialty