Healthcare Provider Details

I. General information

NPI: 1528921137
Provider Name (Legal Business Name): SANDRIA PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 SE STONEMILL DR # 105
VANCOUVER WA
98684-3545
US

IV. Provider business mailing address

1234 SW 18TH AVE APT 306
PORTLAND OR
97205-1754
US

V. Phone/Fax

Practice location:
  • Phone: 360-261-6032
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHARM.PH.61529245
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: