Provider Demographics
NPI:1548711575
Name:SUSAN H HAM
Entity type:Organization
Organization Name:SUSAN H HAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:562-402-0500
Mailing Address - Street 1:18009 NORWALK BLVD
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-4255
Mailing Address - Country:US
Mailing Address - Phone:562-402-0500
Mailing Address - Fax:562-402-0520
Practice Address - Street 1:18009 NORWALK BLVD
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-4255
Practice Address - Country:US
Practice Address - Phone:562-402-0500
Practice Address - Fax:562-402-0520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY545723336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164647OtherPK