Provider Demographics
NPI:1265032510
Name:FUNDERBURK, SANDRA LEE
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LEE
Last Name:FUNDERBURK
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 1:1627 EAGLE BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:TX
Mailing Address - Zip Code:76579-3338
Mailing Address - Country:US
Mailing Address - Phone:254-718-4518
Mailing Address - Fax:254-778-0578
Practice Address - Street 1:3401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1902
Practice Address - Country:US
Practice Address - Phone:254-778-4636
Practice Address - Fax:254-778-0578
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
TX36345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist