Provider Demographics
NPI:1730365883
Name:CUCULICH, SUSAN L
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:CUCULICH
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 1:4975 BEAR RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-4156
Mailing Address - Country:US
Mailing Address - Phone:315-451-7454
Mailing Address - Fax:315-451-4848
Practice Address - Street 1:4975 BEAR RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-4156
Practice Address - Country:US
Practice Address - Phone:315-451-7454
Practice Address - Fax:315-451-4848
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01201014Medicaid