Provider Demographics
NPI:1790322550
Name:LE, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LE
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 1:41266 SCARBOROUGH LN
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2892
Mailing Address - Country:US
Mailing Address - Phone:248-470-4458
Mailing Address - Fax:
Practice Address - Street 1:41266 SCARBOROUGH LN
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2892
Practice Address - Country:US
Practice Address - Phone:248-470-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-28
Last Update Date:2019-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036440183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist