Provider Demographics
NPI:1578883690
Name:NIA, SAM (RPH)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:
Last Name:NIA
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 1:17266 SATICOY
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406
Mailing Address - Country:US
Mailing Address - Phone:818-345-1543
Mailing Address - Fax:
Practice Address - Street 1:17266 SATICOY ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-2103
Practice Address - Country:US
Practice Address - Phone:818-345-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50071183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist