Provider Demographics
NPI:1396357380
Name:KING, SANDEE WALL (RPH)
Entity Type:Individual
Prefix:
First Name:SANDEE
Middle Name:WALL
Last Name:KING
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 1:301 N DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2349
Mailing Address - Country:US
Mailing Address - Phone:662-846-5781
Mailing Address - Fax:
Practice Address - Street 1:301 N DAVIS AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2349
Practice Address - Country:US
Practice Address - Phone:662-846-5781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-010479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist