Provider Demographics
NPI:1710583380
Name:SAMUEL, JERRIN
Entity Type:Individual
Prefix:
First Name:JERRIN
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9181 DUPONT PL
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6475
Mailing Address - Country:US
Mailing Address - Phone:561-603-1043
Mailing Address - Fax:
Practice Address - Street 1:9181 DUPONT PL
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6475
Practice Address - Country:US
Practice Address - Phone:561-603-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61791183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist