Provider Demographics
NPI:1891039061
Name:SAMUEL, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:SAMUEL
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 1:4073 13TH STREET
Mailing Address - Street 2:ATTN:- ST CLOUD PHARMACY
Mailing Address - City:ST. CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769
Mailing Address - Country:US
Mailing Address - Phone:407-733-3498
Mailing Address - Fax:
Practice Address - Street 1:4073 13TH STREET
Practice Address - Street 2:ST CLOUD PHARMACY
Practice Address - City:ST. CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769
Practice Address - Country:US
Practice Address - Phone:407-733-3498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL37307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist