Provider Demographics
NPI:1104511955
Name:CUNDIFF, SAMUEL WALLACE JR (RPH)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:WALLACE
Last Name:CUNDIFF
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 PREAKNESS COURT
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-6500
Mailing Address - Country:US
Mailing Address - Phone:540-580-6756
Mailing Address - Fax:
Practice Address - Street 1:550 OLD FRANKLIN TURNPIKE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151
Practice Address - Country:US
Practice Address - Phone:540-484-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202006868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist