Provider Demographics
NPI:1508443649
Name:NELSON, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:NELSON
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 1:1613 VINCENT PL
Mailing Address - Street 2:
Mailing Address - City:PORT NECHES
Mailing Address - State:TX
Mailing Address - Zip Code:77651-1100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1613 VINCENT PL
Practice Address - Street 2:
Practice Address - City:PORT NECHES
Practice Address - State:TX
Practice Address - Zip Code:77651-1100
Practice Address - Country:US
Practice Address - Phone:318-581-5337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022590183500000X
TX63326183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist