Provider Demographics
NPI:1972995181
Name:SARSAM, LANA
Entity type:Individual
Prefix:
First Name:LANA
Middle Name:
Last Name:SARSAM
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 1:4463 ECTON LN E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-1893
Mailing Address - Country:US
Mailing Address - Phone:904-885-0166
Mailing Address - Fax:
Practice Address - Street 1:4463 ECTON LN E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-1893
Practice Address - Country:US
Practice Address - Phone:904-885-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 52878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist