Provider Demographics
NPI:1003429309
Name:SANSOM, KEVIN ROGER
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROGER
Last Name:SANSOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833A DENZIL AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-6552
Mailing Address - Country:US
Mailing Address - Phone:901-497-3674
Mailing Address - Fax:
Practice Address - Street 1:2385 NASHVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4144
Practice Address - Country:US
Practice Address - Phone:270-393-8979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY021434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist