Provider Demographics
NPI:1548555444
Name:EAGLE, SANDRA
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:EAGLE
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 1:1501 E SAN MARNAN DR
Mailing Address - Street 2:T-1792
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-4300
Mailing Address - Country:US
Mailing Address - Phone:319-226-6761
Mailing Address - Fax:319-226-6761
Practice Address - Street 1:1501 E SAN MARNAN DR
Practice Address - Street 2:T-1792
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-4300
Practice Address - Country:US
Practice Address - Phone:319-226-6761
Practice Address - Fax:319-226-6761
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist