Provider Demographics
NPI:1336474758
Name:PUTT, SALLY RENEA (PHARMD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:RENEA
Last Name:PUTT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1000
Mailing Address - Country:US
Mailing Address - Phone:336-547-1752
Mailing Address - Fax:
Practice Address - Street 1:1126 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1000
Practice Address - Country:US
Practice Address - Phone:336-547-1752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-04
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20585183500000X
MSE-010539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist