Provider Demographics
NPI:1154735785
Name:SAMUEL K. STUCKI
Entity type:Organization
Organization Name:SAMUEL K. STUCKI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:STUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-313-0123
Mailing Address - Street 1:568 W TELEGRAPH ST # 3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-1596
Mailing Address - Country:US
Mailing Address - Phone:435-627-8848
Mailing Address - Fax:
Practice Address - Street 1:568 W TELEGRAPH ST # 3
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-1596
Practice Address - Country:US
Practice Address - Phone:435-627-8848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9012398-1703332B00000X, 3336C0003X, 3336C0004X, 335G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No335G00000XSuppliersMedical Foods Supplier