Provider Demographics
NPI:1033247119
Name:FENN, SAMUEL J (RPH)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:FENN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3539 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32310-6314
Mailing Address - Country:US
Mailing Address - Phone:850-576-5072
Mailing Address - Fax:850-562-2261
Practice Address - Street 1:3539 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32310-6314
Practice Address - Country:US
Practice Address - Phone:850-576-5072
Practice Address - Fax:850-562-2261
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10631183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist