Provider Demographics
NPI:1093194409
Name:LOTFALLA, SAMEH
Entity Type:Individual
Prefix:
First Name:SAMEH
Middle Name:
Last Name:LOTFALLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 GRASS VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-3714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 GRASS VALLEY HWY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-3714
Practice Address - Country:US
Practice Address - Phone:530-885-9381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist