Provider Demographics
NPI:1851719066
Name:SAMPSEL, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SAMPSEL
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 1:25555 YEARSLEY RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-9266
Mailing Address - Country:US
Mailing Address - Phone:937-243-8523
Mailing Address - Fax:
Practice Address - Street 1:25555 YEARSLEY RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-9266
Practice Address - Country:US
Practice Address - Phone:937-243-8523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03114930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist