Provider Demographics
NPI:1730779349
Name:BASS, SALLY COLLMANN (RPH)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:COLLMANN
Last Name:BASS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 S. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901
Mailing Address - Country:US
Mailing Address - Phone:434-394-0113
Mailing Address - Fax:
Practice Address - Street 1:1538 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901
Practice Address - Country:US
Practice Address - Phone:434-394-0113
Practice Address - Fax:434-394-0143
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009048183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202009048OtherPHARMACIST LICENSE