Provider Demographics
NPI:1508462607
Name:SPARKS OVIATT, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:SPARKS OVIATT
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 1:621 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SOUTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-2833
Mailing Address - Country:US
Mailing Address - Phone:651-249-4125
Mailing Address - Fax:
Practice Address - Street 1:6775 YORK AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2514
Practice Address - Country:US
Practice Address - Phone:952-925-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist