=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669554846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA PULLIAM CORREA PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 WATERS AVE
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31404-6220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-350-6337
-----------------------------------------------------
Fax | 912-350-7457
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 CATALINA DR
-----------------------------------------------------
City | TYBEE ISLAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31328-9105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-786-5944
-----------------------------------------------------
Fax | 912-350-7457
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | GA 012621
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------