Provider Demographics
NPI:1649749441
Name:SAMUEL, JOE
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:SAMUEL
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 1:10034 RAVELLO BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-5489
Mailing Address - Country:US
Mailing Address - Phone:239-565-8395
Mailing Address - Fax:
Practice Address - Street 1:2330 PALM RIDGE RD STE 12
Practice Address - Street 2:
Practice Address - City:SANIBEL
Practice Address - State:FL
Practice Address - Zip Code:33957-3278
Practice Address - Country:US
Practice Address - Phone:239-472-6188
Practice Address - Fax:239-472-6144
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT75127183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician