Provider Demographics
NPI:1508415928
Name:ITH, SAM OL (RPH)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:OL
Last Name:ITH
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 1:270 FARMINGTON AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1965
Mailing Address - Country:US
Mailing Address - Phone:860-679-8076
Mailing Address - Fax:
Practice Address - Street 1:270 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1909
Practice Address - Country:US
Practice Address - Phone:860-679-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8385183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist