Provider Demographics
NPI:1083145700
Name:SAMOK, ROTHA
Entity Type:Individual
Prefix:
First Name:ROTHA
Middle Name:
Last Name:SAMOK
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 1:1301 PINOLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-1384
Mailing Address - Country:US
Mailing Address - Phone:510-243-4311
Mailing Address - Fax:510-243-4308
Practice Address - Street 1:1301 PINOLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-1384
Practice Address - Country:US
Practice Address - Phone:510-243-4311
Practice Address - Fax:510-243-4308
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54918183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist