MEDICARE: MR. ALVIN M. SANDBERG R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P1200X	Pharmacotherapy Pharmacist	7868	TN
2	1835P1200X	Pharmacotherapy Pharmacist	RPH018909	GA
3	1835P1200X	Pharmacotherapy Pharmacist	0001797	VT

General Provider Information

NPI Number	:	1033117536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALVIN M. SANDBERG R.PH.

Provider Business Mailing Address
First Line	:	240 FLAGSTONE DR NE
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37323-5199
Country	:	US
Telephone Number	:	423-473-0225
Fax Number	:

Provider Business Practice Location Address
First Line	:	240 FLAGSTONE DR NE
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37323-5199
Country	:	US
Telephone Number	:	423-473-0225
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	07/08/2007

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