Provider Demographics
NPI:1639645591
Name:MITCHELL, SAMANTHA JO (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:JO
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PHARMD
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 528
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453
Mailing Address - Country:US
Mailing Address - Phone:573-885-0885
Mailing Address - Fax:573-885-0882
Practice Address - Street 1:1375 E 10TH ST SUITE B
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-364-9616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018026729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist