Provider Demographics
NPI:1881381408
Name:TREVINO, SUSANNA
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:TREVINO
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 1:4530 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-1423
Mailing Address - Country:US
Mailing Address - Phone:215-455-7330
Mailing Address - Fax:215-455-2990
Practice Address - Street 1:4530 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-1423
Practice Address - Country:US
Practice Address - Phone:215-455-7330
Practice Address - Fax:215-455-2990
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA30229643183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician