Provider Demographics
NPI:1215576954
Name:IVEY, SAMUEL JAMES (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JAMES
Last Name:IVEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-1004
Mailing Address - Country:US
Mailing Address - Phone:314-752-5722
Mailing Address - Fax:
Practice Address - Street 1:3430 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-1004
Practice Address - Country:US
Practice Address - Phone:314-772-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019024410183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist