Provider Demographics
NPI:1447401963
Name:SANDOVAL, BRYAN ANDRE (RPH)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ANDRE
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2089
Mailing Address - Country:US
Mailing Address - Phone:719-587-3885
Mailing Address - Fax:
Practice Address - Street 1:327 MAIN
Practice Address - Street 2:
Practice Address - City:ANTONITO
Practice Address - State:CO
Practice Address - Zip Code:81120
Practice Address - Country:US
Practice Address - Phone:719-376-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16713183500000X
NV11224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist