Provider Demographics
NPI:1821701962
Name:SAMLALL, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:SAMLALL
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 1:29 CAMDEN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-3504
Mailing Address - Country:US
Mailing Address - Phone:413-949-2962
Mailing Address - Fax:
Practice Address - Street 1:22 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:VERNON ROCKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06066-2439
Practice Address - Country:US
Practice Address - Phone:860-870-6765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0015346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist