Provider Demographics
NPI:1376645788
Name:SANSUM CLINIC
Entity type:Organization
Organization Name:SANSUM CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUGHTERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:805-563-6162
Mailing Address - Street 1:215 PESETAS LN
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93110-1416
Mailing Address - Country:US
Mailing Address - Phone:805-964-4831
Mailing Address - Fax:805-964-1562
Practice Address - Street 1:215 PESETAS LN
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1416
Practice Address - Country:US
Practice Address - Phone:805-964-4831
Practice Address - Fax:805-964-1562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY373103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2065991OtherPK
CAPHA37310Medicaid
2065991OtherPK