Provider Demographics
NPI:1639450083
Name:SANDOVAL, GEORGE A (RPH)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:A
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 OSUNA RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6125
Mailing Address - Country:US
Mailing Address - Phone:505-345-3568
Mailing Address - Fax:505-345-1542
Practice Address - Street 1:338 OSUNA RD NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6125
Practice Address - Country:US
Practice Address - Phone:505-345-3568
Practice Address - Fax:505-345-1542
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM00004989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist