Provider Demographics
NPI:1154933554
Name:MO, SANDY
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:MO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10S370 KINGERY HWY
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6140
Mailing Address - Country:US
Mailing Address - Phone:630-655-2733
Mailing Address - Fax:
Practice Address - Street 1:10S370 KINGERY HWY
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-6140
Practice Address - Country:US
Practice Address - Phone:630-655-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist