Provider Demographics
NPI:1497399984
Name:SAMAHA, JORDAN ASHLEY
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ASHLEY
Last Name:SAMAHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:ASHLEY
Other - Last Name:LAURENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4921 PRETTY LAKE AVE APT 219
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-2028
Mailing Address - Country:US
Mailing Address - Phone:985-212-4410
Mailing Address - Fax:
Practice Address - Street 1:13500 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:BOUTTE
Practice Address - State:LA
Practice Address - Zip Code:70039-3500
Practice Address - Country:US
Practice Address - Phone:985-331-1886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202218534183500000X
LAPST.023269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist