Provider Demographics
NPI:1811592702
Name:SAMMAN, MISTY KAY
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:KAY
Last Name:SAMMAN
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 1:50 SAGAMORE PKWY S
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4747
Mailing Address - Country:US
Mailing Address - Phone:765-448-1325
Mailing Address - Fax:
Practice Address - Street 1:50 SAGAMORE PKWY S
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4747
Practice Address - Country:US
Practice Address - Phone:765-448-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019015A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist