Provider Demographics
NPI:1326310137
Name:CIMINO, SAM P (RPH)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:P
Last Name:CIMINO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8348 BROOKINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-8605
Mailing Address - Country:US
Mailing Address - Phone:318-422-4663
Mailing Address - Fax:
Practice Address - Street 1:2107 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3105
Practice Address - Country:US
Practice Address - Phone:318-742-5590
Practice Address - Fax:318-742-8457
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist