Provider Demographics
NPI:1225191695
Name:SORAWAT, SALLY A (RPH)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:SORAWAT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 N 49TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203
Mailing Address - Country:US
Mailing Address - Phone:701-772-5302
Mailing Address - Fax:
Practice Address - Street 1:1395 COLUMBIA RD S
Practice Address - Street 2:MEDICAP PHARMACY
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-746-1800
Practice Address - Fax:701-746-4040
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3435183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist