Provider Demographics
NPI:1649423625
Name:ANSONG, SAMSON
Entity Type:Individual
Prefix:
First Name:SAMSON
Middle Name:
Last Name:ANSONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 LOVEDALE LN
Mailing Address - Street 2:UNIT J
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-2366
Mailing Address - Country:US
Mailing Address - Phone:202-479-0255
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:610-834-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207667183500000X
MD17783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist