Provider Demographics
NPI:1184226821
Name:SAMPLES, PHIL
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:
Last Name:SAMPLES
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 1:204 TOWN CENTER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-9540
Mailing Address - Country:US
Mailing Address - Phone:304-575-5472
Mailing Address - Fax:304-574-1283
Practice Address - Street 1:204 TOWN CENTER RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-9540
Practice Address - Country:US
Practice Address - Phone:304-575-5472
Practice Address - Fax:304-574-1283
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0004158183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist