Healthcare Provider Details

I. General information

NPI: 1255651410
Provider Name (Legal Business Name): SALLY ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 MANZANITA AVE
CARMICHAEL CA
95608-1724
US

IV. Provider business mailing address

4010 MANZANITA AVE
CARMICHAEL CA
95608-1724
US

V. Phone/Fax

Practice location:
  • Phone: 916-482-4930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number37283
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11478
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: