Provider Demographics
NPI:1538418199
Name:WILLENBRINK, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WILLENBRINK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MALLARD POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:OLD MONROE
Mailing Address - State:MO
Mailing Address - Zip Code:63369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1349 E REPUBLIC AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-887-9451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012027983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist