Provider Demographics
NPI:1508189416
Name:SAMPLE, SHAUN (RPH)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:SAMPLE
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 1:500 S MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5317
Mailing Address - Country:US
Mailing Address - Phone:607-277-1772
Mailing Address - Fax:607-277-5890
Practice Address - Street 1:500 S MEADOW ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5317
Practice Address - Country:US
Practice Address - Phone:607-277-1772
Practice Address - Fax:607-277-5890
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY052605OtherPHARMACIST LICENSE #