Provider Demographics
NPI:1053783001
Name:SANFORD, J SCOTT (RPH)
Entity type:Individual
Prefix:MR
First Name:J
Middle Name:SCOTT
Last Name:SANFORD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 SEGER AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-3401
Mailing Address - Country:US
Mailing Address - Phone:712-490-8732
Mailing Address - Fax:
Practice Address - Street 1:4100 SEGER AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-3401
Practice Address - Country:US
Practice Address - Phone:712-490-8732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist