Provider Demographics
NPI:1740564848
Name:SANDOVAL, LEA ANNE (RPH)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:ANNE
Last Name:SANDOVAL
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 1:16775 BRIDGEPORT ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2902
Mailing Address - Country:US
Mailing Address - Phone:714-963-9816
Mailing Address - Fax:
Practice Address - Street 1:17522 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6802
Practice Address - Country:US
Practice Address - Phone:714-596-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 43939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist