Provider Demographics
NPI:1518530047
Name:LEO, SANDRA JANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JANE
Last Name:LEO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 MAIN ST APT 7
Mailing Address - Street 2:
Mailing Address - City:FORESTON
Mailing Address - State:MN
Mailing Address - Zip Code:56330-9427
Mailing Address - Country:US
Mailing Address - Phone:612-501-3979
Mailing Address - Fax:320-532-2499
Practice Address - Street 1:200 ELM ST N
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-7901
Practice Address - Country:US
Practice Address - Phone:320-532-2491
Practice Address - Fax:320-532-2499
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125156333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy