Provider Demographics
NPI:1639559073
Name:SAMUEL, ERNESTO (RPH, MBA)
Entity Type:Individual
Prefix:MR
First Name:ERNESTO
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WALKER WAY
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205
Mailing Address - Country:US
Mailing Address - Phone:518-608-1060
Mailing Address - Fax:518-608-6109
Practice Address - Street 1:15 WALKER WAY
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205
Practice Address - Country:US
Practice Address - Phone:518-608-1060
Practice Address - Fax:518-608-1060
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist