Healthcare Provider Details

I. General information

NPI: 1144928540
Provider Name (Legal Business Name): SANDRA JEAN TIERNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 02/16/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WALMART 1275 E 2ND STREET
FRANKLIN OH
45005
US

IV. Provider business mailing address

1947 MEADOWSWEET DR
LEBANON OH
45036-4077
US

V. Phone/Fax

Practice location:
  • Phone: 937-704-0809
  • Fax: 937-704-0820
Mailing address:
  • Phone: 419-654-4138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberOP.017188-SC
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: