Provider Demographics
NPI:1437541513
Name:ANDERSEN, SARA SUE
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:SUE
Last Name:ANDERSEN
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 1:17979 COBBLESTONE WAY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-2161
Mailing Address - Country:US
Mailing Address - Phone:712-304-0871
Mailing Address - Fax:
Practice Address - Street 1:17979 COBBLESTONE WAY
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-2161
Practice Address - Country:US
Practice Address - Phone:712-304-0871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN810308183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist