Provider Demographics
NPI:1851647994
Name:BALLENGER, SAMMY DALE (RPH)
Entity Type:Individual
Prefix:MR
First Name:SAMMY
Middle Name:DALE
Last Name:BALLENGER
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 1:6073 KANAKA AVE
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-3920
Mailing Address - Country:US
Mailing Address - Phone:530-589-5687
Mailing Address - Fax:
Practice Address - Street 1:6073 KANAKA AVE
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-3920
Practice Address - Country:US
Practice Address - Phone:530-589-5687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist