Provider Demographics
NPI:1043817463
Name:SAMSON, ANGELLA
Entity Type:Individual
Prefix:
First Name:ANGELLA
Middle Name:
Last Name:SAMSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 AVENUE R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4434
Mailing Address - Country:US
Mailing Address - Phone:718-866-5119
Mailing Address - Fax:
Practice Address - Street 1:1346 GRANVILLE PAYNE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11239-2103
Practice Address - Country:US
Practice Address - Phone:718-642-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0672003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY067200OtherNYSED LICENSE NUMBER