Provider Demographics
NPI:1205316668
Name:DANIELL-MEDINA, SANDRA N/A
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:N/A
Last Name:DANIELL-MEDINA
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 1:220 ADRIAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3501
Mailing Address - Country:US
Mailing Address - Phone:917-757-6001
Mailing Address - Fax:
Practice Address - Street 1:91 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062
Practice Address - Country:US
Practice Address - Phone:860-479-2667
Practice Address - Fax:860-747-5580
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT106641835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care