Provider Demographics
NPI:1063801389
Name:SAM, PISETH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:PISETH
Middle Name:
Last Name:SAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4080
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-0080
Mailing Address - Country:US
Mailing Address - Phone:562-208-2735
Mailing Address - Fax:
Practice Address - Street 1:1280 DANA DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-4038
Practice Address - Country:US
Practice Address - Phone:530-223-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71918183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist