Provider Demographics
NPI:1043806318
Name:TALLY, SAMANTHA ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:TALLY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ANN
Other - Last Name:SCHROER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:4018 N LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3714
Mailing Address - Country:US
Mailing Address - Phone:512-459-9090
Mailing Address - Fax:512-371-1246
Practice Address - Street 1:4018 N LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3714
Practice Address - Country:US
Practice Address - Phone:512-459-9090
Practice Address - Fax:512-371-1246
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46209183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist