Provider Demographics
NPI:1295002871
Name:SIDRAK, SAMIA JOSEPH (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SAMIA
Middle Name:JOSEPH
Last Name:SIDRAK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 BLACKHEATH CT
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-5820
Mailing Address - Country:US
Mailing Address - Phone:843-293-9571
Mailing Address - Fax:
Practice Address - Street 1:5020 DICK POND RD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6814
Practice Address - Country:US
Practice Address - Phone:843-293-6664
Practice Address - Fax:843-293-6856
Is Sole Proprietor?:No
Enumeration Date:2011-11-25
Last Update Date:2011-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPI 1194818559Medicaid