Provider Demographics
NPI:1104251511
Name:TAHERI, SAM (PHARM D)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:TAHERI
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2S624 AVENUE VENDOME
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1074
Mailing Address - Country:US
Mailing Address - Phone:630-788-3585
Mailing Address - Fax:
Practice Address - Street 1:2S624 AVENUE VENDOME
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1074
Practice Address - Country:US
Practice Address - Phone:630-788-3585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.296790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist