Provider Demographics
NPI:1497831374
Name:SANDEEN, RODGER FRED (RPH)
Entity Type:Individual
Prefix:MR
First Name:RODGER
Middle Name:FRED
Last Name:SANDEEN
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 1:21022 200TH AVE
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-9359
Mailing Address - Country:US
Mailing Address - Phone:231-796-7473
Mailing Address - Fax:
Practice Address - Street 1:21022 200TH AVE.
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307
Practice Address - Country:US
Practice Address - Phone:231-796-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist