Provider Demographics
NPI:1689222051
Name:SADURAL, JACQUELINE MAY TUALLA
Entity Type:Individual
Prefix:
First Name:JACQUELINE MAY
Middle Name:TUALLA
Last Name:SADURAL
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 1:1317 MUIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-2963
Mailing Address - Country:US
Mailing Address - Phone:209-954-8509
Mailing Address - Fax:
Practice Address - Street 1:2708 S ROCHESTER RD STE 204
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4577
Practice Address - Country:US
Practice Address - Phone:248-237-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI19141130557183500000X
CARPH80502183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist