Provider Demographics
NPI:1801443114
Name:RILES, SUSAN DIANE (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:RILES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:DIANE
Other - Last Name:WILKINSON-RILES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:5713 HIGHWAY 178 E
Mailing Address - Street 2:
Mailing Address - City:POTTS CAMP
Mailing Address - State:MS
Mailing Address - Zip Code:38659-9237
Mailing Address - Country:US
Mailing Address - Phone:662-544-9420
Mailing Address - Fax:
Practice Address - Street 1:1235 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1429
Practice Address - Country:US
Practice Address - Phone:877-864-7952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE08347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist