Provider Demographics
NPI:1023612140
Name:BITTAR, SALLY
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:BITTAR
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 1:1825 SOUTHCROSS DR W APT 2301
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-7976
Mailing Address - Country:US
Mailing Address - Phone:612-801-3387
Mailing Address - Fax:
Practice Address - Street 1:18275 KENRICK AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7306
Practice Address - Country:US
Practice Address - Phone:952-892-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124088183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist