Provider Demographics
NPI:1518395102
Name:PUCKETT, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:PUCKETT
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 1:672 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-764-2300
Practice Address - Fax:970-764-2324
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist