Provider Demographics
NPI:1790031094
Name:SAMUEL, JOHN MINA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MINA
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ROUTE 304 STE 4
Mailing Address - Street 2:
Mailing Address - City:BARDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2146
Mailing Address - Country:US
Mailing Address - Phone:845-507-0555
Mailing Address - Fax:845-507-0012
Practice Address - Street 1:301 ROUTE 304 STE 4
Practice Address - Street 2:
Practice Address - City:BARDONIA
Practice Address - State:NY
Practice Address - Zip Code:10954-2146
Practice Address - Country:US
Practice Address - Phone:845-507-0555
Practice Address - Fax:845-507-0012
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist