Provider Demographics
NPI:1821878380
Name:VICKERS, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:VICKERS
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 1:1101 NW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-8905
Mailing Address - Country:US
Mailing Address - Phone:954-356-5038
Mailing Address - Fax:
Practice Address - Street 1:1101 NW 1ST ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-8905
Practice Address - Country:US
Practice Address - Phone:954-356-5038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS54953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist