Healthcare Provider Details

I. General information

NPI: 1255766580
Provider Name (Legal Business Name): SANFORD CARE SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2423 E CLAIREMONT AVE
EAU CLAIRE WI
54701-6724
US

IV. Provider business mailing address

2423 E CLAIREMONT AVE
EAU CLAIRE WI
54701-6724
US

V. Phone/Fax

Practice location:
  • Phone: 715-833-6770
  • Fax: 715-833-6773
Mailing address:
  • Phone: 715-833-6770
  • Fax: 715-833-6773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number9221-42
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number9221-42
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number9221-42
License Number StateWI

VIII. Authorized Official

Name: MR. GILLIAM R SANFORD
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 715-833-6770