Provider Demographics
NPI:1306492814
Name:SANDER, KEVIN (RPH)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SANDER
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 1:712 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-2627
Mailing Address - Country:US
Mailing Address - Phone:814-864-0653
Mailing Address - Fax:
Practice Address - Street 1:5430 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509
Practice Address - Country:US
Practice Address - Phone:814-868-4624
Practice Address - Fax:814-864-3928
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP040613L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist