Provider Demographics
NPI:1083346878
Name:ROSERO, SAMANTHA LY
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LY
Last Name:ROSERO
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 1:8707 SKOKIE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2272
Mailing Address - Country:US
Mailing Address - Phone:312-623-5595
Mailing Address - Fax:
Practice Address - Street 1:8707 SKOKIE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2272
Practice Address - Country:US
Practice Address - Phone:312-623-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILH5B5J7Q7183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician