Provider Demographics
NPI:1205103207
Name:MALLAK, SARAH L (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SARAH
Middle Name:L
Last Name:MALLAK
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 1:10905 ULYSSES ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3827
Mailing Address - Country:US
Mailing Address - Phone:763-252-0687
Mailing Address - Fax:763-252-0693
Practice Address - Street 1:10905 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3827
Practice Address - Country:US
Practice Address - Phone:763-252-0687
Practice Address - Fax:763-252-0693
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN119774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist