Provider Demographics
NPI:1063189140
Name:SANSOM, JUSTIN DARRELL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DARRELL
Last Name:SANSOM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 COLEMAN RD
Mailing Address - Street 2:
Mailing Address - City:ELKHORN CITY
Mailing Address - State:KY
Mailing Address - Zip Code:41522-7864
Mailing Address - Country:US
Mailing Address - Phone:606-213-7228
Mailing Address - Fax:
Practice Address - Street 1:911 BYPASS RD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1602
Practice Address - Country:US
Practice Address - Phone:606-430-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0222441835C0207X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835C0207XPharmacy Service ProvidersPharmacistCompounded Sterile Preparations