Basic Information
Provider Information | |||||||||
NPI: | 1467052316 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SONNENBERG | ||||||||
FirstName: | LEE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THAI | ||||||||
OtherFirstName: | DUNG | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHARMD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 157 GARY HATFIELD WAY | ||||||||
Address2: |   | ||||||||
City: | HUNTSVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727403730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4797381270 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 157 GARY HATFIELD WAY | ||||||||
Address2: |   | ||||||||
City: | HUNTSVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727403730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4797381270 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2020 | ||||||||
LastUpdateDate: | 10/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 68775 | CA | N |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | PD12120 | AR | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.