Provider Demographics
NPI:1619577293
Name:LANG, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LANG
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:PO BOX 762
Mailing Address - Street 2:
Mailing Address - City:MC GEHEE
Mailing Address - State:AR
Mailing Address - Zip Code:71654-0762
Mailing Address - Country:US
Mailing Address - Phone:870-222-6474
Mailing Address - Fax:
Practice Address - Street 1:427 HIGHWAY 425 N
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-4015
Practice Address - Country:US
Practice Address - Phone:870-367-3559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist