Provider Demographics
NPI:1063012284
Name:SANFORD, KATIE MORIAH (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MORIAH
Last Name:SANFORD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:MORIAH
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7016
Mailing Address - Country:US
Mailing Address - Phone:479-431-8289
Mailing Address - Fax:
Practice Address - Street 1:201 WALTON WAY
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7016
Practice Address - Country:US
Practice Address - Phone:479-431-8289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist