Provider Demographics
NPI:1871246207
Name:PISTEK, SAMANTHA VICTORIA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:VICTORIA
Last Name:PISTEK
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 1:137 CROSSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1526
Mailing Address - Country:US
Mailing Address - Phone:917-932-4759
Mailing Address - Fax:
Practice Address - Street 1:758 ARTHUR KILL RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2121
Practice Address - Country:US
Practice Address - Phone:718-317-5085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068778333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy