Provider Demographics
NPI:1710576459
Name:KOENIG, SANDRA BETH (RPH)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:BETH
Last Name:KOENIG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1104
Mailing Address - Country:US
Mailing Address - Phone:630-351-4375
Mailing Address - Fax:
Practice Address - Street 1:121 E LAKE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1104
Practice Address - Country:US
Practice Address - Phone:630-351-4375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-17
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015753183500000X
IL051300597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE