Provider Demographics
NPI:1689739583
Name:DUNCAN, SAM GILLARD (RPH)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:GILLARD
Last Name:DUNCAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3804 MOSCOW MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-8113
Mailing Address - Country:US
Mailing Address - Phone:208-883-7632
Mailing Address - Fax:
Practice Address - Street 1:209 W. MAIN AVE
Practice Address - Street 2:RITZVILLE DRUG COMPANY
Practice Address - City:RITZVILLE
Practice Address - State:WA
Practice Address - Zip Code:99169
Practice Address - Country:US
Practice Address - Phone:509-659-0250
Practice Address - Fax:509-659-1763
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00015721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6093603Medicaid
0425850001Medicare ID - Type Unspecified
WA6093603Medicaid