Provider Demographics
NPI:1255766580
Name:SANFORD CARE SERVICES, INC
Entity type:Organization
Organization Name:SANFORD CARE SERVICES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:GILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-833-6770
Mailing Address - Street 1:2423 E CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6724
Mailing Address - Country:US
Mailing Address - Phone:715-833-6770
Mailing Address - Fax:715-833-6773
Practice Address - Street 1:2423 E CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6724
Practice Address - Country:US
Practice Address - Phone:715-833-6770
Practice Address - Fax:715-833-6773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9221-423336C0004X, 3336L0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9221-42OtherPHARMACY LICENSE