Provider Demographics
NPI:1811281819
Name:WADE, SANDRA KAYE (RPH)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:KAYE
Last Name:WADE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:782 MILES STILL RD
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-3134
Mailing Address - Country:US
Mailing Address - Phone:912-284-1668
Mailing Address - Fax:
Practice Address - Street 1:1803 KNIGHT AVE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8018
Practice Address - Country:US
Practice Address - Phone:912-285-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH019605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist