Healthcare Provider Details

I. General information

NPI: 1700350527
Provider Name (Legal Business Name): SANDRA EISENMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 HOLLYWOOD BLVD
HOLLYWOOD FL
33021-6611
US

IV. Provider business mailing address

4519 HOLLYWOOD BLVD
HOLLYWOOD FL
33021-6611
US

V. Phone/Fax

Practice location:
  • Phone: 954-987-4125
  • Fax:
Mailing address:
  • Phone: 954-987-4125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberRPT38699
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: