Provider Demographics
NPI:1730523358
Name:SANDERLIN, TED ALLEN
Entity type:Individual
Prefix:
First Name:TED
Middle Name:ALLEN
Last Name:SANDERLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:KNIPPA
Mailing Address - State:TX
Mailing Address - Zip Code:78870-0043
Mailing Address - Country:US
Mailing Address - Phone:210-844-6146
Mailing Address - Fax:
Practice Address - Street 1:250 E MAIN ST
Practice Address - Street 2:
Practice Address - City:UVALDE
Practice Address - State:TX
Practice Address - Zip Code:78801-5639
Practice Address - Country:US
Practice Address - Phone:830-278-3915
Practice Address - Fax:830-591-2033
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist