Provider Demographics
NPI:1528652294
Name:SANDBERG, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 KENSINGTON CT
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:NC
Mailing Address - Zip Code:28630-8669
Mailing Address - Country:US
Mailing Address - Phone:828-396-0199
Mailing Address - Fax:
Practice Address - Street 1:3 KENSINGTON CT
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:NC
Practice Address - Zip Code:28630-8669
Practice Address - Country:US
Practice Address - Phone:828-396-0199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist