Provider Demographics
NPI:1386085645
Name:TASIC, SAMANTHA ROSE (PHARM D)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:ROSE
Last Name:TASIC
Suffix:
Gender:F
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 1:421 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:FOX RIVER GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60021-1814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119-9118
Practice Address - Country:US
Practice Address - Phone:630-365-9176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296599183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist