Provider Demographics
NPI:1619571528
Name:SAMUEL, LETHA MEPPURATHU
Entity Type:Individual
Prefix:
First Name:LETHA
Middle Name:MEPPURATHU
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 AVONLEA DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-7104
Mailing Address - Country:US
Mailing Address - Phone:972-772-8744
Mailing Address - Fax:
Practice Address - Street 1:2935 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-5804
Practice Address - Country:US
Practice Address - Phone:972-882-1266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist