Provider Demographics
NPI:1689065989
Name:SOURS, ANGELA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:SOURS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 W CALUMET ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1462
Mailing Address - Country:US
Mailing Address - Phone:920-734-3882
Mailing Address - Fax:920-734-4799
Practice Address - Street 1:511 W CALUMET ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1462
Practice Address - Country:US
Practice Address - Phone:920-734-3882
Practice Address - Fax:920-734-4799
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12999-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist