Provider Demographics
NPI:1831767730
Name:MANSOUR, SALLY (PHARMD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MANSOUR
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 1:321 E MAIN ST UNIT 1012
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1785
Mailing Address - Country:US
Mailing Address - Phone:901-319-3661
Mailing Address - Fax:
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022188961835P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0200XPharmacy Service ProvidersPharmacistPediatrics