Provider Demographics
NPI:1326437898
Name:THEN, SARA M
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:M
Last Name:THEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:M
Other - Last Name:BONANNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:505 SW PINE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-1962
Mailing Address - Country:US
Mailing Address - Phone:716-444-1172
Mailing Address - Fax:
Practice Address - Street 1:505 SW PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-1962
Practice Address - Country:US
Practice Address - Phone:239-458-8130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI31272183500000X
FLPS57101183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPSI31272OtherDEPARTMENT OF HEALTH