Provider Demographics
NPI:1770171860
Name:BRENEVILLE, SANDRA D (PHARM D)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:BRENEVILLE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-2630
Mailing Address - Country:US
Mailing Address - Phone:508-697-6946
Mailing Address - Fax:508-279-0640
Practice Address - Street 1:19 SUMMER ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-2630
Practice Address - Country:US
Practice Address - Phone:508-697-6946
Practice Address - Fax:508-279-0640
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH22632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist