Provider Demographics
NPI:1508533415
Name:WASKO, SAMANTHA KAY (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KAY
Last Name:WASKO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 PIPESTONE RD
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-2315
Mailing Address - Country:US
Mailing Address - Phone:269-934-6710
Mailing Address - Fax:
Practice Address - Street 1:1920 PIPESTONE RD
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-2315
Practice Address - Country:US
Practice Address - Phone:269-934-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI530241400183500000X
IN26029453A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist