Provider Demographics
NPI:1215286703
Name:MATHEWS, SAMANTHA ANNE (PHARMD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANNE
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 1ST PL APT 2
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-5232
Mailing Address - Country:US
Mailing Address - Phone:815-351-1100
Mailing Address - Fax:
Practice Address - Street 1:2169 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3625
Practice Address - Country:US
Practice Address - Phone:310-515-3783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2014-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67954183500000X
IL051296027183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist