Provider Demographics
NPI:1710341573
Name:SAFO, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SAFO
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 1:3200 MADISON AVE UNIT 18
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2045
Mailing Address - Country:US
Mailing Address - Phone:646-418-1094
Mailing Address - Fax:
Practice Address - Street 1:3710 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3613
Practice Address - Country:US
Practice Address - Phone:203-371-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0012087183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist