Provider Demographics
NPI:1164958195
Name:HARTMAN, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:HARTMAN
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 1:875 ENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3617
Mailing Address - Country:US
Mailing Address - Phone:860-741-3014
Mailing Address - Fax:860-741-5434
Practice Address - Street 1:875 ENFIELD ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3617
Practice Address - Country:US
Practice Address - Phone:860-741-3014
Practice Address - Fax:860-741-5434
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT07889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist