Provider Demographics
NPI:1487303921
Name:GABRIEL, SAM
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:GABRIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2664 STAR GRASS CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-3471
Mailing Address - Country:US
Mailing Address - Phone:813-245-0229
Mailing Address - Fax:
Practice Address - Street 1:705 1ST ST S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3602
Practice Address - Country:US
Practice Address - Phone:863-294-7487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist