Provider Demographics
NPI:1134605017
Name:SANSOUCIE, IRENE (PHARMD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:SANSOUCIE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HARBOR CT
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-7516
Mailing Address - Country:US
Mailing Address - Phone:314-398-1198
Mailing Address - Fax:
Practice Address - Street 1:4333 BUTLER HILL RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3717
Practice Address - Country:US
Practice Address - Phone:314-894-2484
Practice Address - Fax:314-894-2591
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011026615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist