Provider Demographics
NPI:1659654218
Name:LE, SANDRA J (PHARMD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:LE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4809 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6622
Mailing Address - Country:US
Mailing Address - Phone:217-414-6836
Mailing Address - Fax:
Practice Address - Street 1:106 ILLINI BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:IL
Practice Address - Zip Code:62684-8480
Practice Address - Country:US
Practice Address - Phone:217-414-6836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292699183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist