Provider Demographics
NPI:1568695096
Name:EMERSON, SAMUEL JUSTIN (RPH)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JUSTIN
Last Name:EMERSON
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 1:700 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3703
Mailing Address - Country:US
Mailing Address - Phone:575-562-3851
Mailing Address - Fax:
Practice Address - Street 1:700 E 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3703
Practice Address - Country:US
Practice Address - Phone:575-762-3851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007231183500000X
TX36216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist