Provider Demographics
NPI:1558496471
Name:SANDERS, WYNN (R PH)
Entity Type:Individual
Prefix:
First Name:WYNN
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 SUSAN DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7733
Mailing Address - Country:US
Mailing Address - Phone:662-332-1376
Mailing Address - Fax:
Practice Address - Street 1:1427 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7000
Practice Address - Country:US
Practice Address - Phone:662-378-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE5177183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist