Provider Demographics
NPI:1770116972
Name:SANDOVAL, KRISTIN ALISA
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ALISA
Last Name:SANDOVAL
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 1:20422 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1676
Mailing Address - Country:US
Mailing Address - Phone:313-308-1033
Mailing Address - Fax:313-308-1036
Practice Address - Street 1:20422 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1676
Practice Address - Country:US
Practice Address - Phone:313-308-1033
Practice Address - Fax:313-308-1036
Is Sole Proprietor?:No
Enumeration Date:2020-02-16
Last Update Date:2020-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020402801835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist